Association between more complex special care needs and overweight status and adolescents' difficulty with dental caries

OBJECTIVE

Little is known about dental caries experience in adolescents with overweight and complex special health care needs (SHCNs).

METHODS

Adolescent data (10-17 years) from the 2016-2020 National Survey of Children's Health (n = 91,196) was analyzed. The sample was grouped into the following: more complex SHCN and overweight, more complex SHCN without overweight, less complex SHCN and overweight, less complex SHCN without overweight, no SHCN but with overweight, and neither SHCN nor overweight. A multivariable-adjusted logistic regression model was conducted.

RESULTS

Adolescents with more complex SHCNs with (OR: 1.82, 95% CI: 1.44-2.30, p < 0.001) or without overweight (OR: 1.51, 95% CI: 1.30-1.76, p < 0.001) were at higher odds of experiencing dental caries compared to healthy adolescents. No significant associations were observed between adolescents with less complex or no SHCN regardless of the overweight status with healthy adolescents.

CONCLUSIONS

Adolescents with more complex SHCNs, irrespective of overweight status, experienced a higher caries severity than adolescents with no SHCNs or overweight.

Health insurance coverage and experiences of intimate partner violence and postpartum abuse screening among rural US residents who gave birth 2016-2020

PURPOSE

Intimate partner violence (IPV) is elevated among rural residents and contributes to maternal morbidity and mortality. Postpartum health insurance expansion efforts could address multiple causes of maternal morbidity and mortality, including IPV. The objective of this study was to describe the relationship between perinatal health insurance, IPV, and postpartum abuse screening among rural US residents.

METHODS

Using 2016-2020 data on rural residents from the Pregnancy Risk Assessment Monitoring System, we assessed self-report of experiencing physical violence by an intimate partner and rates of abuse screening at postpartum visits. Health insurance at childbirth and postpartum was categorized as private, Medicaid, or uninsured. We also measured insurance transitions from childbirth to postpartum (continuous private, continuous Medicaid, Medicaid to private, and Medicaid to uninsured).

FINDINGS

IPV rates varied by health insurance status at childbirth, with the highest rates among Medicaid beneficiaries (7.7%), compared to those who were uninsured (1.6%) or privately insured (1.6%). When measured by insurance transitions, the highest IPV rates were reported by those with continuous Medicaid coverage (8.6%), followed by those who transitioned from Medicaid at childbirth to private insurance (5.3%) or no insurance (5.9%) postpartum. Nearly half (48.1%) of rural residents lacked postpartum abuse screening, with the highest proportion among rural residents who were uninsured at childbirth (66.1%) or postpartum (52.1%).

CONCLUSION

Rural residents who are insured by Medicaid before or after childbirth are at elevated risk for IPV. Medicaid policy efforts to improve maternal health should focus on improving detection and screening for IPV among rural residents.

Integrating Fall Prevention Strategies into EMS Services to Reduce Falls and Associated Healthcare Costs for Older Adults

Purpose

The purpose of this study is to detail the implementation of fall prevention initiatives through emergency medical services (EMS) and associated outcomes.

Methods

Paramedics with MedStar Mobile Healthcare utilized the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention model to screen and direct intervention through 9-1-1 emergency response, High Utilization Group (HUG), and 30-day Hospital Readmission Avoidance (HRA) programs. Outcomes from 9-1-1 calls measured the number of older adults screened for falls and identified risk factors. The HUG and HRA programs measured change in quality of life with EuroQol-5D, referral service utilization, falls, emergent healthcare utilization, and hospital readmission data. Analysis included costs associated with reduced healthcare usage.

Results

Emergency paramedics provided fall risk screening for 50.5% (n=45,090) of adults aged 65 and older and 59.3% were at risk of falls, with 48.1% taking medications known to increase the risk of falls. Services provided through the HUG and HRA programs, along with additional needed referral services, resulted in a 37.2% reduction in fall-related 9-1-1 calls and a 29.5% increase in overall health status related to quality of life. Analysis of the HUG program revealed potential savings of over $1 million with a per-patient enrolled savings of $19,053. The HRA program demonstrated a 16.4% hospital readmission rate, in comparison to a regional average of 30.2%, and a cost-savings of $4.95 million or $15,618 per enrolled patient.

Conclusion

Implementation of the STEADI model into EMS services provides an effective and cost-saving model for addressing fall prevention for older adults, provides meaningful and impactful improvement for older adults, and could serve as a model for other EMS programs.

Non-operating revenue is an important source of funding for rural hospitals, especially those that are government-owned

PURPOSE

Non-operating revenue (NOR), derived from investments, contributions, government appropriations, and medical space rentals, can contribute to financial stability of hospitals by offsetting operating losses and improving profitability. NOR might benefit rural hospitals that often face intense financial pressures. However, little is known about how much rural hospitals rely on NOR and if certain organizational characteristics are associated with differences in NOR.

METHODS

Healthcare Cost Report Information System data from 2011 to 2019 were used to analyze sources of revenue among Critical Access Hospitals (CAHs) and Rural Prospective Payment System (R-PPS) hospitals through descriptive statistics and regression models. Reliance on NOR was measured by the percentage of total revenue from non-operating sources.

FINDINGS

Results indicate that both CAHs and R-PPS hospitals rely on NOR; however, CAHs have a higher percentage of total revenue derived from non-operating sources (3.2%) as compared to R-PPS hospitals (1.9%) (p < 0.001). Government-owned hospitals have significantly higher reliance on NOR than other ownership types. System affiliation also influences reliance on NOR. Lastly, results suggest that NOR may play a role in improving overall profit margins.

CONCLUSIONS

As rural hospitals disproportionately face challenges related to declining profitability and the risk for closure, they may rely on NOR to continue to strengthen financial performance and provide health care to their communities. However, NOR is not guaranteed, and reliance on NOR further reiterates the value of stable, adequate reimbursement to guard against fluctuations in NOR.

Feasibility of providing web-based education to patients prior to kidney transplant evaluation

BACKGROUND

We previously developed web-based education to be used by patients prior to kidney transplant (KTX) evaluation. The current feasibility study evaluated patients' intervention uptake and barriers, and staff experiences of the clinic-wide implementation in preparation for a definitive comparative effectiveness trial.

METHODS

Web links and login instructions to view 17 educational videos designed to promote KTX access were delivered via email or text to adults referred to a single transplant center between 10/2020 and 3/2021. Patient barriers were recorded. Non-completers were allowed to view the resources in the clinic. N = 7 clinic staff were interviewed about their experiences of in-clinic delivery of the web-education. Interviews were recorded with field notes and coded using simple content analysis. Patient characteristics and 30-month KTX access were examined with Chi-square, t-tests, and log-rank tests.

RESULTS

Of 210 patients, 71% completed the self-education remotely (completers), 16% attempted but did not complete remotely (attempters), and 13% declined the web link invitation (decliners). Implementation barriers included technology access and use difficulties, unstable internet connectivity, limited staff time in clinic to facilitate technology use by patients, and limited technology attentiveness by patients in clinic. In 3-group comparisons, remote decliners were older with worse estimated posttransplant survival scores, and attempters were younger, more often Medicaid insured, and lived in higher area deprivation; both were more often deemed ineligible for KTX than completers. Between-group time-to-transplantation was non-significant (p = .571).

CONCLUSION

The majority of patients accessed the web-education remotely; however, more vulnerable demographic populations reported greater problems accessing web-education. In-clinic delivery was burdensome to staff and patients. Future adaptive implementation strategies are needed to allow for adequate patient education.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Prevent Diabetes in People With Prediabetes

Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.

The National Clinical Care Commission Report to Congress: Summary and Next Steps

The U.S. is experiencing an epidemic of type 2 diabetes. Socioeconomically disadvantaged and certain racial and ethnic groups experience a disproportionate burden from diabetes and are subject to disparities in treatment and outcomes. The National Clinical Care Commission (NCCC) was charged with making recommendations to leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC determined that diabetes cannot be addressed simply as a medical problem but must also be addressed as a societal problem requiring social, clinical, and public health policy solutions. As a result, the NCCC's recommendations address policies and programs of both non-health-related and health-related federal agencies. The NCCC report, submitted to the U.S. Congress on 6 January 2022, makes 39 specific recommendations, including three foundational recommendations that non-health-related and health-related federal agencies coordinate their activities to better address diabetes, that all federal agencies and departments ensure that health equity is a guiding principle for their policies and programs that impact diabetes, and that all Americans have access to comprehensive and affordable health care. Specific recommendations are also made to improve general population-wide policies and programs that impact diabetes risk and control, to increase awareness and prevention efforts among those at high risk for type 2 diabetes, and to remove barriers to access to effective treatments for diabetes and its complications. Finally, the NCCC recommends that an Office of National Diabetes Policy be established to coordinate the activities of health-related and non-health-related federal agencies to address diabetes prevention and treatment. The NCCC urges Congress and the Secretary of Health and Human Services to implement these recommendations to protect the health and well-being of the more than 130 million Americans at risk for and living with diabetes.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Improve Diabetes Treatment and Reduce Complications

The Treatment and Complications subcommittee of the National Clinical Care Commission focused on factors likely to improve the delivery of high-quality care to all people with diabetes. The gap between available resources and the needs of people living with diabetes adversely impacts both treatment and outcomes. The Commission's recommendations are designed to bridge this gap. At the patient level, the Commission recommends reducing barriers and streamlining administrative processes to improve access to diabetes self-management training, diabetes devices, virtual care, and insulin. At the practice level, we recommend enhancing programs that support team-based care and developing capacity to support technology-enabled mentoring interventions. At the health system level, we recommend that the Department of Health and Human Services routinely assess the needs of the health care workforce and ensure funding of training programs directed to meet those needs. At the health policy level, we recommend establishing a process to identify and ensure pre-deductible insurance coverage for high-value diabetes treatments and services and developing a quality measure that reduces risk of hypoglycemia and enhances patient safety. We also identified several areas that need additional research, such as studying the barriers to uptake of diabetes self-management education and support, exploring methods to implement team-based care, and evaluating the importance of digital connectivity as a social determinant of health. The Commission strongly encourages Congress, the Department of Health and Human Services, and other federal departments and agencies to take swift action to implement these recommendations to improve health outcomes and quality of life among people living with diabetes.

The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes

The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission

The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.

Integration of Case-Based Dialogue to Enhance Medical Students' Understanding of Using Health Communication to Address Social Determinants of Health

BACKGROUND AND OBJECTIVES

With the ever-growing diversity within our communities, it is imperative that we integrate social determinants of health (SDOH) such as racial disparity, economic instability, lack of transportation, intimate partner violence, and limited social supports, and the importance of health literacy into undergraduate medical education. By incorporating evidence-based curriculum on the disproportionality within healthcare faced by racial and ethnic minorities, we have the opportunity to develop more culturally sensitive providers. The purpose of this study was to assess the impact of a case-based debrief experience on medical students' knowledge about how social determinants of health can impact health and healthcare within a family medicine clinical setting and their intent to practice in an underserved community.

METHODS

We utilized a retrospective paired-sample t-test analysis of program data from 640 third-year medical students who engaged in a family medicine clerkship between July 2020, and April 2022. For inclusion in the study, students must have engaged in a case-based exercise and corresponding small group debrief around the impact of social determinants of health on patient care.

RESULTS

We found a statistically significant improvement in students' reported knowledge about SDOH, as well as the confidence and intent to work with and care for individuals of diverse cultural and socioeconomic backgrounds.

CONCLUSION

Medical students must have the knowledge and self-efficacy to understand how social determinants of health can impact health and healthcare within a family medicine clinical setting. As a result of integrating more active learning strategies such as the case-base and debrief experience, students may have a more robust medical education experience.

Health Management Workforce Capacity-Building in Liberia, Post-Ebola

Following the Ebola crisis in Liberia in 2014-15, the Liberian Ministry of Health developed a strategy to build a fit-for-purpose health workforce, focusing on both health care providers and health managers. To help fulfill national capacity-building goals for health management, a team of faculty, staff, and practitioners from the Yale School of Medicine, the University of Liberia, the National Public Health Institute of Liberia, and the Ministry of Health collaboratively developed and launched the health management program in Liberia in July 2017. The team worked to build specific management and leadership competencies for healthcare workers serving in management and leadership roles in Liberia's health sector using two concurrent strategies-1) implementation of a hospital-based partnership-mentorship model in the two largest hospitals in the capital city of Monrovia, and 2) establishment of an executive education-style advanced Certificate in Health Systems Leadership and Management at the University of Liberia. Here we describe the health management program in Liberia, its focus, and its evolution from program launch in 2017 to the present, as well as ongoing efforts to transition program activities to local partner ownership by the end of 2021.

Strategies for Success: Simple Education Interventions to Equip Nursing Students in Rural Liberia

Severe shortages of skilled health workforce remain a major barrier to universal health coverage in low income countries including Liberia where nurses and midwives form more than 50% of the health workforce. According to the 2018 Service Availability and Readiness Assessment (SARA) report, Liberia has 10.7 core healthcare workers per 10,000 people, far below the WHO benchmark of 23/10,000 people. High quality training for nurses and midwives is one of the most important strategies to addressing these health workforce shortages. Since 2015, William V.S Tubman University (TU) faculty and Partners in Health (PIH) have partnered in nursing and midwifery education to address nursing and midwifery workforce shortages in Southeast Liberia. In our collaboration we have sought to not only increase the quantity of graduate nurses and midwives but also improve the quality of the training to ensure they are equipped to serve the population. TU strives to produce highly competent generic nurses who will excel in their clinical practice and future specialized training. By applying the theory of deliberate practice, learners are allowed to practice and self-evaluate repeatedly until they attain proficiency. Simulation training was adopted early in the training of nurses and midwives at TU to ensure students are well-prepared for real-life patient care. TU also established a preceptorship program to ensure that students receive skilled mentorship during clinical rotations. Internship for graduating senior Nursing/Midwifery students, where they focus on enhancing psychomotor and assessment skills, professional communication, safety and organization, medication administration and documentation, ensures successful integration into clinical practice after graduation. This progression of the student nurse or midwife from the exposure in the skills lab during pre-clinical modules, to individual preceptorship during clinical rotations to a structured internship experience with an intensive pre-internship "boot camp" have been the major innovations that have helped our partnership flourish. The foundation of these interventions is strong and sustained investment in nursing and midwifery faculty both at the university and the health facilities.

Gaps, Challenges, and Opportunities for Global Health Leadership Training

Background

Global Health Leadership (GHL) programs are essential for training emerging health care professionals to be effective leaders. Synthesizing knowledge acquired through experience implementing GHL programs can inform future recommendations for GHL.

Objective

To describe the lessons learned, highlighting gaps, challenges and opportunities, during implementation of two GHL capacity building programs, namely the Afya Bora Consortium Fellowship in Global Health Leadership and the Sustaining Technical and Analytic Resources (STAR) fellowship and internship program for global health professionals.

Methods

A mixed methods case-comparison study was conducted, using qualitative data (expert opinion) collected from the Program Directors in order to understand the experiences of the two GHL programs. A structured response guide was used to assess the overall experience in GHL program implementation, operational challenges and reported gaps. Afya Bora and STAR have been implemented for 8 and 2.5 years respectively. Thus, the analysis reflects a snapshot of the two programs at different stages.

Findings

The results reflect knowledge gained through extensive experience in implementing the two GHL programs. Afya Bora has trained 188 multi-disciplinary fellows, and 100% of the African fellows are engaged in leadership positions in government departments and non-governmental organizations (NGOs) in their countries. STAR has placed 147 participants (89 fellows and 58 interns) in more than 25 countries globally. Both programs were successful in strengthening south-south and north-south collaborations for a common goal of improving global health. Implementation of both fellowships identified room for improvement in operational procedures and financing of the programs, and highlighted knowledge and skills gaps, as well as challenges in sustainability of the training programs.

Conclusions

Afya Bora and STAR have had significant impact and have contributed to changing the leadership landscape in global health. Future GHL programs should address sustainability in terms of financing, delivery modalities and domestic integration of knowledge.

Who Gets What? Describing the Non-supervisory Training and Supports Received by Home Visiting Staff Members and its Relationship with Turnover

The early childhood home visiting field lacks a basic understanding of home visiting program staff members' receipt of on-the-job training from experts outside of their programs who are not their immediate colleagues or supervisors. To address this gap, we created a unique dataset by asking program leaders to log the external technical assistance (TA) that staff members received, and we collected a survey from 288 of the same staff members. We performed descriptive analyses to learn how many hours of TA staff members were receiving, what topics the TA most commonly addressed, and what formats (e.g., in-person or virtual/remote, individual, or group) the TA was most commonly provided in. We then associated characteristics of the TA received with staff and program characteristics, as well as with staff members' turnover. Multilevel analyses showed the TA supports that home visiting staff members received differed by role (home visitor or supervisor) and program characteristics, including home visiting model-Nurse Family Partnership (NFP) or Parents as Teachers (PAT)-program size, and maturity. About 23% of the home visiting staff members left their programs over the course of 18 months. PAT staff members were more likely to leave their programs than NFP staff members. We did not find that characteristics of TA received were predictive of staff members' turnover. Implications and the need for further research are discussed.

Changing Rural and Urban Enrollment in State Medicaid Programs

Purpose. From October 2013—before implementation of the Affordable Care Act (ACA)—to November 2016, Medicaid enrollment grew by 27 percent. However, very little attention has been paid to date to how changes in Medicaid enrollment vary within states across the rural-urban continuum. This brief reports and analyzes changes in enrollment in metropolitan, micropolitan, and rural (noncore) areas in both expansion states (those that used ACA funding to expand Medicaid coverage) and nonexpansion states (those that did not use ACA funding to expand Medicaid coverage). The findings suggest that growth has been uneven across rural-urban geography, and that Medicaid enrollment growth is lower in rural counties, particularly in nonexpansion states. Key Findings. (1) Medicaid growth rates in metropolitan counties in nonexpansion states from 2012 to 2015 were twice as large as in rural counties (14 percent compared to 7 percent). (2) In contrast, the differential in growth rates between metropolitan, micropolitan, and rural counties was much less dramatic in expansion states (growth rates of 43 percent, 38 percent, and 38 percent, respectively). (3) Analysis at the state level shows much variability across the states, even when controlling for expansion status. For example, some states with an above-average rural population, such as Tennessee and Idaho, had higher-than-average enrollment increases, with strong rural increases, while other states with similar proportions of rural residents, such as Nebraska, Oklahoma, Maine, and Wyoming, experienced enrollment decreases in micropolitan and/or rural counties. (4) States’ pre-ACA Medicaid eligibility levels for parents and children affected the potential for growth. For example, some states that had higher eligibility levels (e.g., Maryland and Illinois) experienced lower Medicaid growth rates from 2012 to 2015, in part because their baseline enrollment was higher. (5) In the expansion states of Colorado and Nevada, which both have State-Based Marketplaces (SBMs), enrollment increases were over four times the overall average.

2016 Rural Enrollment in Health Insurance Marketplaces, by State

Purpose. In this brief, cumulative county-level enrollment in Health Insurance Marketplaces (HIMs) through March 2016 is presented for state HIMs operated as Federally Facilitated Marketplaces (FFMs) and for those operated as Federally Supported State-Based Marketplaces (FS-SBMs). Enrollment rates in metropolitan and non-metropolitan areas of each state, defined as the percentage of “potential market” participants selecting plans, are presented. Monitoring annual enrollment rates provides a gauge of how well state outreach and enrollment efforts are proceeding and helps identify states with strong non-metropolitan enrollment as models for other states to emulate. Key Findings. (1) Cumulative enrollment in the HIMs in non-metropolitan counties has grown to about 1.4 million in 2016, representing 40 percent of the potential market in non-metropolitan counties. (2) Estimated enrollment rates varied considerably across the United States. In particular, estimated enrollment rates in non-metropolitan areas were substantially higher than in metropolitan areas in Hawaii, Illinois, Michigan, Montana, Maine, Nebraska, Wisconsin, and Wyoming. (3) The states that achieved the highest absolute non-metropolitan enrollment totals were Michigan, Georgia, Missouri, North Carolina, Texas, and Wisconsin. Of these, Michigan, North Carolina, and Wisconsin also had non-metropolitan enrollment rates above 50 percent. (4) About half of all states, evenly distributed by Medicaid expansion status but mostly concentrated in the Midwestern census region, had higher enrollment growth in non-metropolitan areas from 2015 to 2016, and in fact aggregated non-metropolitan growth was greater than metropolitan growth in both expansion categories.