Objective: The objective of this study was to examine the association of patient- and county-level factors with the emergency department (ED) visits among adult fee-for-service (FFS) Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. Methods: A cross-sectional design using retrospective observational data was implemented. Patient-level data were obtained from 2010 Medicaid Analytic eXtract files. Information on county-level health-care resources was obtained from the Area Health Resource file and County Health Rankings file. Results: In adjusted analyses, the following patient-level factors were associated with higher number of ED visits: African Americans (incidence rate ratios [IRR] = 1.47), Hispanics (IRR = 1.63), polypharmacy (IRR = 1.89), and tobacco use (IRR = 2.23). Patients with complex chronic illness had a higher number of ED visits (IRR = 3.33). The county-level factors associated with ED visits were unemployment rate (IRR = 0.94) and number of urgent care clinics (IRR = 0.96). Conclusion: Patients with complex healthcare needs had a higher number of ED visits as compared to those without complex healthcare needs. The study results provide important baseline context for future policy analysis studies around Medicaid expansion options.

Using original survey data from a national sample of small cities in the USA, this paper explores the perceptions of policy-makers as to what matters for the viability of their downtowns. How do policy-makers of small cities perceive the viability of their downtowns? What policies and programs are associated with perceptions of viability? The results show policy-makers across the USA believe their downtown districts have strengths and weaknesses. Perceived strengths include safety from crime, access to government services, pedestrian safety, cultural opportunities, availability of restaurants and tolerance of diversity. Perceived weaknesses include a lack of available grocery stores, hotels, housing and economic competitiveness with areas outside of downtown. These perceptions indicate policy-makers are concerned about their downtown's ability to compete in the marketplace and that they feel more positively about issues perceived to be within their locus of control. A controlled multivariate model suggests the presence of mixed-use zoning, a Main Street program, the ability for downtown to compete with businesses outside of the downtown, higher levels of cooperation among key stakeholders and quality of life ratings are all significantly related to whether policy-makers perceive their downtowns to be viable. These findings are important because they examine competing and complementary explanations of downtown development and viability for small cities for the first time. They also point to the need to address the continual tensions between downtown and suburban development with innovative policy solutions especially for small cities.

The Health Insurance Marketplace was designed to increase the affordability of health insurance. The success of the marketplace depends on people’s awareness and use of it. In a statewide mail survey of West Virginians, we found that respondents’ awareness of the West Virginia Health Insurance Marketplace increased from 2013 to 2014. However, large percentages of respondents continued to be unaware of the availability of federal subsidies and were unsure of their personal eligibility for these subsidies. It is essential that awareness and enrollment efforts continue and that they be expanded in novel ways to continue growth in access to health insurance through the marketplace.