Prescription Benzodiazepine Use in Privately Insured U.S. Children and Adolescents.

INTRODUCTION: Benzodiazepines are commonly prescribed in the U.S. but entail safety concerns, including dependency. In pediatrics, many indications lack trial data. Authors aimed to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use. METHODS: The study cohort included children (aged 3-12 years) and adolescents (aged 13-17 years) initiating prescription benzodiazepine treatment (≥3 days' supply) from January 2010 to September 2015 in a U.S. commercial claims database. Potential indications included selected ICD-9-CM diagnoses (≤30 days prior). Long-term (≥6 months) benzodiazepine treatment was estimated with Kaplan-Meier estimation and modified Poisson regression identified independent predictors of long-term benzodiazepine treatment (analysis completed in 2018). RESULTS: Of 24,504 children and 61,046 adolescents initiating benzodiazepines, 62% of the children and 68% of the adolescents had a potential indication. Anxiety disorders were the most common indication, with mental health indications more common among adolescents (45%) than children (23%) and epilepsy and movement disorders higher in children. Recent opioid prescriptions were common before benzodiazepine initiation (children, 22%; adolescents, 21%). Six percent of the initiators became long-term benzodiazepine users. Potential indication, provider contact, psychotropic medication, and chronic conditions independently predicted long-term benzodiazepine treatment in adolescents and children. CONCLUSIONS: U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. Long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.

Budget Impact of Dabrafenib and Trametinib in Combination as Adjuvant Treatment of BRAF V600E/K Mutation-Positive Melanoma from a U.S. Commercial Payer Perspective.

BACKGROUND: Before the approval of dabrafenib and trametinib in combination, there were no approved therapies in the adjuvant setting that target the RAS/RAF/MEK/ERK pathway. OBJECTIVE: To evaluate the budget impact of dabrafenib and trametinib in combination for adjuvant treatment of patients with BRAF V600 mutation-positive resected Stage IIIA, IIIB, or IIIC melanoma from a U.S. commercial payer perspective using data from the COMBI-AD trial, as well as other sources. METHODS: The budget impact of dabrafenib and trametinib in combination for patients with BRAF V600E/K mutation-positive, resected Stage IIIA, IIIB, or IIIC melanoma was evaluated from the perspective of a hypothetical population of 1 million members with demographic characteristics consistent with those of a commercially insured U.S. insurance plan (i.e., adults aged less than 65 years) using an economic model developed in Microsoft Excel. The model compared melanoma-related health care costs over a 3-year projection period under 2 scenarios: (1) a reference scenario in which dabrafenib and trametinib are assumed to be unavailable for adjuvant therapy and (2) a new scenario in which the combination is assumed to be available. Treatments potentially displaced by dabrafenib and trametinib were assumed to include observation, high-dose interferon alpha-2b, ipilimumab, and nivolumab. Costs considered in the model include those of adjuvant therapies and treatment of locoregional and distant recurrences. The numbers of patients eligible for treatment with dabrafenib and trametinib were based on data from cancer registries, published sources, and assumptions. Treatment mixes under the reference and new scenarios were based on market research data, clinical expert opinion, and assumptions. Probabilities of recurrence and death were based on data from the COMBI-AD trial and an indirect treatment comparison. Medication costs were based on wholesale acquisition cost prices. Costs of distant recurrence were from a health insurance claims study. RESULTS: In a hypothetical population of 1 million commercially insured members, 48 patients were estimated to become eligible for treatment with dabrafenib and trametinib in combination over the 3-year projection period; in the new scenario, 10 patients were projected to receive such treatment. Cumulative costs of melanoma-related care were estimated to be $6.3 million in the reference scenario and $6.9 million in the new scenario. The budget impact of dabrafenib and trametinib in combination was an increase of $549 thousand overall and 1.5 cents per member per month. CONCLUSIONS: For a hypothetical U.S. commercial health plan of 1 million members, the budget impact of dabrafenib and trametinib in combination as adjuvant treatment for melanoma is likely to be relatively modest and within the range of published estimates for oncology therapies. These results may assist payers in making coverage decisions regarding the use of adjuvant dabrafenib and trametinib in melanoma. DISCLOSURES: Funding for this research was provided to Policy Analysis Inc. (PAI) by Novartis Pharmaceuticals. Stellato, Moynahan, and Delea are employed by PAI. Ndife, Koruth, Mishra, and Gunda are employed by Novartis. Ghate was employed by Novartis at the time of this study and is shareholder in Novartis, Provectus Biopharmaceuticals, and Mannkind Corporation. Gerbasi was employed by PAI at the time of this study and is currently an employee, and stockholder, of Sage Therapeutics. Delea reports grant funding from Merck and research funding from Amgen, Novartis, Sanofi, Seattle Genetics, Takeda, Jazz, EMD Serono, and 21st Century Oncology, unrelated to this work.

Breast, Cervical, and Colorectal Cancer Screening: Patterns Among Women With Medicaid and Commercial Insurance.

INTRODUCTION: Despite healthcare reforms mandating expanded insurance coverage and reduced out-of-pocket costs for preventive care, cancer screening rates remain relatively static. No study has measured cancer screening rates for multiple tests among non-Medicare patients. METHODS: This retrospective, population-based claims analysis, conducted in 2016-2017, of commercially insured and Medicaid-insured women aged 30-59 years enrolled in IBM MarketScan Commercial and Medicaid Databases (containing approximately 90 and 17 million enrollees, respectively) during 2010-2015 describes screening rates for breast, cervical, and colorectal cancer. Key outcomes were (1) proportion screened for breast, cervical, and colorectal cancer among the age-eligible population compared with accepted age-based recommendations and (2) proportion with longer-than-recommended intervals between tests. RESULTS: One half (54.7%) of commercially insured women aged 40-59 years (n=1,538,444) were screened three or more times during the 6-year study period for breast cancer; for Medicaid-insured women (n=78,897), the rates were lower (23.7%). One third (43.4%) of commercially insured and two thirds (68.9%) of Medicaid-insured women had a >2.5-year gap between mammograms. Among women aged 30-59 years, 59.3% of commercially insured women and 31.4% of Medicaid-insured women received two or more Pap tests. The proportion of patients with a >3.5-year gap between Pap tests was 33.9% (commercially insured) and 57.1% (Medicaid-insured). Among women aged 50-59 years, 63.3% of commercially insured women and 47.2% of Medicaid-insured women were screened at least one time for colorectal cancer. Almost all women aged 30-59 years (commercially insured, 99.1%; Medicaid-insured, 98.9%) had at least one healthcare encounter. CONCLUSIONS: Breast and cervical cancer screenings remain underutilized among both commercially insured and Medicaid-insured populations, with lower rates among the Medicaid-insured population. However, almost all women had at least one healthcare encounter, suggesting opportunities for better coordinated care.

PSA screening, prostate biopsy, and treatment of prostate cancer in the years surrounding the USPSTF recommendation against prostate cancer screening.

BACKGROUND: The 2012 United States Preventive Services Task Force recommendation against screening for prostate cancer has impacted rates of prostate-specific antigen (PSA) screening and appears to be associated with declining prostate cancer incidence. Our objective was to characterize health care utilization that may explain these observed trends. METHODS: MarketScan claims, which capture >30 million privately insured patients in the United States, were queried for all men aged 40-64 years for the years 2008-2014. PSA testing, prostate biopsy, prostate cancer diagnosis, and definitive local treatment were determined using associated International Classification of Diseases, Ninth Revision and Current Procedural Terminology, Fourth Edition codes. RESULTS: There were approximately 6 million qualifying men with a full year of data. PSA testing, prostate biopsy, and prostate cancer detection declined significantly between 2009 and 2014, most notably after 2011. The prostate biopsy rate per 100 patients with a PSA test decreased over the study period from 1.95 (95% confidence interval [CI], 1.92-1.97) to 1.52 (95% CI, 1.50-1.54). Prostate cancer incidence per prostate biopsy increased over the study period from 0.36 (95% CI, 0.35-0.36) to 0.39 (95% CI, 0.39-0.40). Of new prostate cancer diagnoses, the proportion managed with definitive local treatment decreased from 69% (95% CI, 69%-70%) to 54% (95% CI, 53%-55%). Both PSA testing and prostate cancer incidence decreased significantly after 2011 (P < .001). CONCLUSION: In a large cohort of privately insured men, PSA testing, prostate biopsy, prostate cancer incidence, and local definitive treatment for prostate cancer decreased between 2008 and 2014, most notably after 2011. This decrease may be driven by differential referral patterns from primary care providers to urologists. Cancer 2018;124:2733-2739. © 2018 American Cancer Society.

Estimating a Change from TRICARE to Commercial Insurance Plans.

Introduction: We estimate the effect on health care spending of an option to change TRICARE. Under the option, which is based on a proposal made by the Military Compensation and Retirement Modernization Commission (MCRMC), most beneficiaries could choose from a range of commercial health networks instead of the current TRICARE plans. Military treatment facilities would become network providers under the commercial plans. Materials and Methods: We used data from the Department of Defense (DoD) to estimate the cost of providing the current health care benefit to working-age retirees and their dependents and survivors, and active duty family members. We then adjusted those data to estimate what the private insurance premiums would be for those groups. Greater details about the methodology can be found in earlier work by the Congressional Budget Office. Because payments by TRICARE to physicians and hospitals are tied to payments made by Medicare, we used the information from studies that compare Medicare payment rates to rates paid to doctors and hospitals by private insurance to estimate what it would cost private insurers to provide approximately the same level of care, with adjustments to account for the higher out-of-pocket costs that beneficiaries would pay under the option. We also made adjustments to account for the possibility that many beneficiaries would decrease their use of the MTFs in favor of private providers, which could increase the overall costs of DoD. We then estimated that increasing the cost sharing to a level found in popular civilian plans would lower overall demand for services by about 10% for military retiree households and about 18% for active duty family members. Results: We estimated that DoD would pay subsidies to retain about half of the excess capacity created by beneficiaries switching their care from MTFs to the private sector. Evaluated at the midpoint of the ranges, the net effect on DoD's budget would be approximately $0, we estimate, but costs could fall in a likely range from about $3 billion in annual savings to about $3 billion in annual costs. Thus, the MCRMC estimate of $3.2 billion implicitly assumed that no excess capacity would be retained by MTFs. In 2031, under current law, the average retiree family is expected to cost the federal government about $24,100 (in 2017 dollars) and that family's out-of-pocket costs are expected to amount to about $1,900. The option would reduce the government's costs for the average retiree family to $23,500, but retiree families could see their out-of-pocket costs rise to $7,500 per year. Conclusion: This article outlined a method of identifying two particular sources of that uncertainty: the extent to which people will receive care outside of MTFs and the extent to which the MTFs can adjust to reductions in demand. For one particular option, we demonstrate that the potential savings from changing the system depends on increasing the share of costs paid by beneficiaries - particularly working-age retirees - and on DoD's ability to reduce excess capacity in the system.

Out-of-Pocket and Health Care Spending Changes for Patients Using Orally Administered Anticancer Therapy After Adoption of State Parity Laws.

Importance: Oral anticancer medications are increasingly important but costly treatment options for patients with cancer. By early 2017, 43 states and Washington, DC, had passed laws to ensure patients with private insurance enrolled in fully insured health plans pay no more for anticancer medications administered by mouth than anticancer medications administered by infusion. Federal legislation regarding this issue is currently pending. Despite their rapid acceptance, the changes associated with state adoption of oral chemotherapy parity laws have not been described. Objective: To estimate changes in oral anticancer medication use, out-of-pocket spending, and health plan spending associated with oral chemotherapy parity law adoption. Design, Setting, and Participants: Analysis of administrative health plan claims data from 2008-2012 for 3 large nationwide insurers aggregated by the Health Care Cost Institute. Data analysis was first completed in 2015 and updated in 2017. The study population included 63 780 adults living in 1 of 16 states that passed parity laws during the study period and who received anticancer drug treatment for which orally administered treatment options were available. Study analysis used a difference-in-differences approach. Exposures: Time period before and after adoption of state parity laws, controlling for whether the patient was enrolled in a plan subject to parity (fully insured) or not (self-funded, exempt via the Employee Retirement Income Security Act). Main Outcomes and Measures: Oral anticancer medication use, out-of-pocket spending, and total health care spending. Results: Of the 63 780 adults aged 18 through 64 years, 51.4% participated in fully insured plans and 48.6% in self-funded plans (57.2% were women; 76.8% were aged 45 to 64 years). The use of oral anticancer medication treatment as a proportion of all anticancer treatment increased from 18% to 22% (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% CI, 0.96-1.13; P = .34) comparing months before vs after parity. In plans subject to parity laws, the proportion of prescription fills for orally administered therapy without copayment increased from 15.0% to 53.0%, more than double the increase (12.3%-18.0%) in plans not subject to parity (P < .001). The proportion of patients with out-of-pocket spending of more than $100 per month increased from 8.4% to 11.1% compared with a slight decline from 12.0% to 11.7% in plans not subject to parity (P = .004). In plans subject to parity laws, estimated monthly out-of-pocket spending decreased by $19.44 at the 25th percentile, by $32.13 at the 50th percentile, and by $10.83 at the 75th percentile but increased at the 90th ($37.19) and 95th ($143.25) percentiles after parity (all P < .001, controlling for changes in plans not subject to parity). Parity laws did not increase 6-month total spending for users of any anticancer therapy or for users of oral anticancer therapy alone. Conclusions and Relevance: While oral chemotherapy parity laws modestly improved financial protection for many patients without increasing total health care spending, these laws alone may be insufficient to ensure that patients are protected from high out-of-pocket medication costs.

Does health insurance coverage fall when nonprofit insurers become for-profits?

In exchange for tax exemptions, Blue Cross and Blue Shield (BCBS) health insurers were expected to provide health insurance to the "bad risks," those for whom coverage was unavailable from other insurers. I present evidence that five years after a BCBS plan converted to for-profit status, the probability of having insurance was 1.4 percentage points higher, a 9% reduction in the uninsured. The increase in coverage does not mask reductions among populations often targeted by public policies. However, there is evidence of increased risk selection which suggests that the bad risks might have been worse off after a conversion.

How Have Health Insurers Performed Financially Under the ACA' Market Rules?

Issue: The Affordable Care Act (ACA) transformed the market for individual health insurance, so it is not surprising that insurers' transition was not entirely smooth. Insurers, with no previous experience under these market conditions, were uncertain how to price their products. As a result, they incurred significant losses. Based on this experience, some insurers have decided to leave the ACA's subsidized market, although others appear to be thriving. Goals: Examine the financial performance of health insurers selling through the ACA's marketplace exchanges in 2015--the market's most difficult year to date. Method: Analysis of financial data for 2015 reported by insurers from 48 states and D.C. to the Centers for Medicare and Medicaid Services. Findings and Conclusions: Although health insurers were profitable across all lines of business, they suffered a 10 percent loss in 2015 on their health plans sold through the ACA's exchanges. The top quarter of the ACA exchange market was comfortably profitable, while the bottom quarter did much worse than the ACA market average. This indicates that some insurers were able to adapt to the ACA's new market rules much better than others, suggesting the ACA's new market structure is sustainable, if supported properly by administrative policy.

More choice in health insurance marketplaces may reduce the value of the subsidies available to low-income enrollees.

Federal subsidies available to enrollees in health insurance Marketplaces are pegged to the premium of the second-lowest-cost silver plan available in each rating area (as defined by each state). People who qualify for the subsidy contribute a percentage of their income to purchase coverage, and the federal government covers the remaining cost up to the price of that premium. Because the number of plans offered and plan premiums vary substantially across rating areas, the effective value of the subsidy may vary geographically. We found that the availability of more plans in a rating area was associated with lower premiums but higher deductibles for enrollees in the second-lowest-cost silver plan. In rating areas with more than twenty plans, the average deductible in the second-lowest-cost silver plan was nearly $1,000 higher than it was in rating areas with fewer than thirteen plans. Because premium costs for second-lowest-cost silver plans are capped, deductibles may be a more salient measure of plan value for enrollees than premiums are. Greater standardization of plans or an alternative approach to calculating the subsidy could provide a more consistent benefit to enrollees across various rating areas.

Management of Newer Antidepressant Medications in U.S. Commercial Health Plans.

BACKGROUND: Private health insurance plays a large role in the U.S. health system, including for many individuals with depression. Private insurers have been actively trying to influence pharmaceutical utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to antidepressant medications. AIMS OF THE STUDY: To report which approaches (e.g., tiered copayments, prior authorization, and step therapy) commercial health plans are employing to manage newer antidepressant medications, and how the use of these approaches has changed since 2003. METHODS: Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded antidepressant medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics. RESULTS: Less than 1% of health plan products excluded any of the six antidepressants studied. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for newer branded antidepressants. This proportion was lower than in 2003, when 71% of products took this approach. In addition, only 2% of products left all the newer branded medications unrestricted, down from 25% in 2003. Multivariate analysis indicated that preferred provider organizations were more likely than other product types to use tier 3 or 4 placement. DISCUSSION: We find that U.S. health plans are using a variety of strategies to manage cost and utilization of newer branded antidepressant medications. Plans appear to be finding that approaches other than exclusion are adequate to meet their cost-management goals for newer branded antidepressants, although they have increased their use of administrative restrictions since 2003. Limitations include lack of information about how administrative restrictions were applied in practice, information on only six medications, and some potential for endogeneity bias in the regression analyses. CONCLUSION: This study has documented substantial use of various restrictions on access to newer branded antidepressants in U.S. commercial health plans. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns. At the same time, it is worth noting that high copayments and administrative requirements can nonetheless be burdensome for some patients. IMPLICATIONS FOR HEALTH POLICY: Health plans' pharmacy management approaches may concern policymakers less than in the early 2000s, due to the lesser distinctiveness of today's branded medications. This may change depending on future drug introductions. IMPLICATIONS FOR FURTHER RESEARCH: Future research should examine the impact of plans' pharmacy management approaches, using patient-level data.

Patient perceptions of asthma-related financial burden: public vs. private health insurance in the United States.

BACKGROUND: Given the complexity of the health insurance market in the United States and the confusion that often stems from these complexities, patient perception about the value of health insurance in managing chronic disease is important to understand. OBJECTIVE: To examine differences between public and private health insurance in perceptions of financial burden with managing asthma, outcomes, and factors that explain these perceptions. METHODS: Secondary analysis was performed using baseline data from a randomized clinical trial that were collected through telephone interviews with 219 African American women seeking services for asthma and reporting perceptions of financial burden with asthma management. Path analysis with multigroup models and multiple variable regression analyses were used to examine associations. RESULTS: For public (P < .001) and private (P < .01) coverage, being married and more educated were indirectly associated with greater perceptions of financial burden through different explanatory pathways. When adjusted for multiple morbidities, asthma control, income, and out-of-pocket expenses, those with private insurance used fewer inpatient (P < .05) and emergency department (P < .001) services compared with those with public insurance. When also adjusted for health insurance, greater financial burden was associated with more urgent office visits (P < .001) and lower quality of life (P < .001). CONCLUSION: African American women who perceive asthma as a financial burden regardless of health insurance report more urgent health care visits and lower quality of life. Burden may be present despite having and being able to generate economic resources and health insurance. Further policy efforts are indicated and special attention should focus on type of coverage.

Direct medical costs and resource use for treating central and branch retinal vein occlusion in commercially insured working-age and Medicare populations.

PURPOSE: To quantify the burden of illness for incident branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) in a commercially insured working-age (commercial) and Medicare US population. METHODS: Retrospective cohort analysis of health care claims from 2003 through 2008 from commercial and Medicare patients with ≥2 outpatient diagnoses for BRVO or CRVO. The index date was the first retinal vein occlusion diagnosis. Patients with medical and pharmacy benefits were followed ≥1 year preindex and then between 1 year and 3 years postindex. Incidence and prevalence of retinal vein occlusion was determined. Burden of illness was compared with matched control subjects without retinal vein occlusion. RESULTS: The commercial sample comprised 1,188 CRVO and 2,252 BRVO cases, whereas the Medicare sample had 2,739 CRVO and 4,573 BRVO cases. Adjusted ratio of case-to-control, all-cause expenditures for commercial patients at 1 year and 3 years postindex were 1.88 and 1.68, respectively, for BRVO and 1.42 and 1.36, respectively, for CRVO. For Medicare patients, these were 1.29 and 1.13, respectively, for BRVO and 1.23 and 1.14, respectively, for CRVO. All comparisons were significant (P < 0.001). CONCLUSION: Health care utilization and expenditures for commercially insured working-age and Medicare patients with BRVO or CRVO were significantly greater than those for control subjects. Retinal vein occlusion development may be a marker for the increased severity of systemic vascular disease.

Targeted erlotinib for first-line treatment of advanced non-small cell lung cancer: a budget impact analysis.

OBJECTIVES: A recent phase III trial showed that patients with advanced non-small cell lung cancer (NSCLC) whose tumors harbor specific EGFR mutations significantly benefit from first-line treatment with erlotinib compared to chemotherapy. This study sought to estimate the budget impact if coverage for EGFR testing and erlotinib as first-line therapy were provided in a hypothetical 500,000-member managed care plan. METHODS: The budget impact model was developed from a US health plan perspective to evaluate administration of the EGFR test and treatment with erlotinib for EGFR-positive patients, compared to non-targeted treatment with chemotherapy. The eligible patient population was estimated from age-stratified SEER incidence data. Clinical data were derived from key randomized controlled trials. Costs related to drug, administration, and adverse events were included. Sensitivity analyses were conducted to assess uncertainty. RESULTS: In a plan of 500,000 members, it was estimated there would be 91 newly diagnosed advanced NSCLC patients annually; 11 are expected to be EGFR-positive. Based on the testing and treatment assumptions, it was estimated that 3 patients in Scenario 1 and 6 patients in Scenario 2 receive erlotinib. Overall health plan expenditures would increase by $0.013 per member per month (PMPM). This increase is largely attributable to erlotinib drug costs, in part due to lengthened progression-free survival and treatment periods experienced in erlotinib-treated patients. EGFR testing contributes slightly, whereas adverse event costs mitigate the budget impact. The budget impact did not exceed $0.019 PMPM in sensitivity analyses. CONCLUSIONS: Coverage for targeted first-line erlotinib therapy in NSCLC likely results in a small budget impact for US health plans. The estimated impact may vary by plan, or if second-line or maintenance therapy, dose changes/interruptions, or impact on patients' quality-of-life were included.

How might the Affordable Care Act's coverage expansion provisions influence demand for medical care?

CONTEXT: The Affordable Care Act (ACA) is predicted to expand health insurance to 25 million individuals. Since insurance reduces the price of medical care, the quantity of services demanded by these newly covered individuals is expected to rise. In this article I provide a comprehensive picture of the demographics, health status, and medical care utilization of the population targeted for the ACA's expansion of coverage, contrasted with that of other nonelderly, insured populations. In addition, I synthesize the current evidence regarding the causal impact of insurance on medical care demand, drawing heavily on recent evidence from Massachusetts and Oregon. METHODS: Using the 2008 to 2010 Medical Expenditure Panel Survey, I conducted bivariate and multivariate analyses to examine differences between the ACA target population and other insured groups. I used the results from the descriptive analysis and quasi-experimental literature to generate "back of the envelope" estimates of the potential impact of the coverage expansion on total medical care utilization by the noninstitutionalized US population. FINDINGS: Comparisons of the potential ACA target population with the privately and publicly insured reveal that the former is younger and more likely to be male. The ACA target population, and particularly the uninsured with incomes under 200% of the federal poverty line, reports lower rates of several medical conditions relative to those of the privately and publicly insured. Future changes in rates of inpatient hospitalization and ED use among the newly insured could vary widely, based on descriptive findings and inferences from the quasi-experimental literature. Results also suggest moderate increases in ambulatory care. Total increases in overall demand for medical care by the newly insured comprise a modest proportion of the aggregate utilization. CONCLUSIONS: With the expected increases in utilization resulting from the coverage expansion, stakeholders will need to monitor local health care delivery system capacity and respond where needed with policy- and/or market-based innovations.