Accounting for the burden and redistribution of health care costs: Who uses care and who pays for it.

OBJECTIVE: To measure the burden of financing health care costs and quantify redistribution among population groups. DATA SOURCES: A synthetic population using data combined from multiple sources, including the Survey of Income and Program Participation (SIPP), Medical Expenditure Panel Survey (MEPS), Kaiser Family Foundation (KFF)/Health Research Educational Trust (HRET) Employer Health Benefits Survey, American Community Survey (ACS), and National Health Expenditure Accounts (NHEA). STUDY DESIGN: We estimate two dollar amounts for each individual in the synthetic population: (a) payments to finance health care services, which includes all payments by a household and their employers to finance health care, including premiums, out-of-pocket payments, federal and state taxes, and other payments; and (b) the dollar value of health care services received, which equals the amount paid to providers for those services. DATA EXTRACTION METHODS: We linked the nationally representative survey data using statistical matching. We allocated health care expenditures from the NHEA to individuals and households based on expenditures reported in the MEPS. PRINCIPAL FINDINGS: We show that higher-income households pay the most to finance health care in dollar amounts, but the burden of payments as a share of income is greater among lower-income households. CONCLUSIONS: Accounting for all sources of payments provides a clear picture of the burden of financing health care costs, and how that burden is spread under our current financing system.

Building a National Culture of Health: Background, Action Framework, Measures, and Next Steps.

Because health is a function of more than medical care, solutions to U.S. health problems must encompass more than reforms to health care systems. But those working to improve health, well-being, and equity still too often find themselves traveling on parallel paths that rarely intersect. In 2013, the Robert Wood Johnson Foundation (RWJF) embarked on a pioneering effort to advance a Culture of Health initiative. A Culture of Health places well-being at the center of every aspect of life, with the goal of enabling everyone in our diverse society to lead healthier lives, now and for generations to come. To put this vision into action, RWJF worked with RAND to develop an action framework that identifies how the nation will work toward achieving these outcomes. This article provides background on the development of this action framework. The Culture of Health action framework is designed around four action areas and one outcome area. Action areas are the core areas in which investment and activity are needed: (1) making health a shared value; (2) fostering cross-sector collaboration to improve well-being; (3) creating healthier, more equitable communities; and (4) strengthening integration of health services and systems. Each action area contains a set of drivers indicating where the United States needs to accelerate change and a set of measures illustrating places for progress. Within the primary Culture of Health outcome---improved population health, well-being, and equity---the authors identified three outcome areas: enhanced individual and community well-being, managed chronic disease and reduced toxic stress, and reduced health care costs.

Insurance Transitions Following the First ACA Open Enrollment Period.

While most of the Affordable Care Act's (ACA's) coverage-related provisions took effect in January 2014, there is limited information on insurance transitions that occurred in the period before and after these changes became operational. In Insurance Transitions Following the First ACA Open Enrollment Period, the authors examine insurance transitions between September 2013 and November 2014 using longitudinal data from the RAND Health Reform Opinion Study, a part of the RAND American Life Panel (ALP). The ALP includes 2,953 respondents-ages 18 to 64, in a population-based sample-who were approached to participate in this data collection. Out of the 2,953 individuals, 2,329 (79 percent) responded in September 2013, and 1,972 (67 percent) responded in November 2014; 1,636 (55 percent) responded in both months, and 1,628 (55 percent) provided clear information about their source of insurance. The authors report the type of coverage people had before the law's major provisions took effect (September 2013) and at the end of the Marketplace enrollment year (November 2014). They estimate that 20.4 million nonelderly adults became newly insured and 7.4 million lost coverage, for a net increase of 12.9 million between September 2013 and November 2014. Among those previously uninsured, most (7.5 million) enrolled in Medicaid, followed by employer plans (7.3 million), the Marketplaces (3.1 million), and other insurance sources. Among those losing coverage, most (3.4 million) lost employer coverage, with the remaining insurance losses spread across a variety of coverage sources. The authors estimate that 7.6 million people enrolled in Marketplace plans; this includes the 3.1 million people who became newly insured in Marketplace plans and another 4.5 million people who transitioned to Marketplace plans from another coverage source. The majority of those insured at baseline (81 percent) experienced no change in source of coverage during the study period, suggesting that disruption from the law has been limited. The majority of Americans continue to be enrolled in employer coverage, and more gained coverage in employer plans than through the ACA's Marketplaces. These findings suggest that the ACA is expanding coverage through a variety of insurance sources, perhaps because the individual mandate is encouraging people to take up insurance offers that they might otherwise have declined.

Methodology of the RAND Health Reform Opinion Study.

The Affordable Care Act has already and will continue to lead to significant changes in health insurance coverage. Understanding insurance transitions is critical to evaluating the success of the reform and to identifying opportunities for improvement. The RAND Health Reform Opinion Study uses the American Life Panel to study transitions in health insurance enrollment from 2013 through 2015. Methodology of the RAND Health Reform Opinion Study provides a description of the methodology the authors use to track health insurance choices between November 2014 and December 2015.

Preparedness of Americans for the Affordable Care Act.

This paper investigates whether individuals are sufficiently informed to make reasonable choices in the health insurance exchanges established by the Affordable Care Act (ACA). We document knowledge of health reform, health insurance literacy, and expected changes in healthcare using a nationally representative survey of the US population in the 5 wk before the introduction of the exchanges, with special attention to subgroups most likely to be affected by the ACA. Results suggest that a substantial share of the population is unprepared to navigate the new exchanges. One-half of the respondents did not know about the exchanges, and 42% could not correctly describe a deductible. Those earning 100-250% of federal poverty level (FPL) correctly answered, on average, 4 out of 11 questions about health reform and 4.6 out of 7 questions about health insurance. This compares with 6.1 and 5.9 correct answers, respectively, for those in the top income category (400% of FPL or more). Even after controlling for potential confounders, a low-income person is 31% less likely to score above the median on ACA knowledge questions, and 54% less likely to score above the median on health insurance knowledge than a person in the top income category. Uninsured respondents scored lower on health insurance knowledge, but their knowledge of ACA is similar to the overall population. We propose that simplified options, decision aids, and health insurance product design to address the limited understanding of health insurance contracts will be crucial for ACA's success.

Changes in Health Insurance Enrollment Since 2013: Evidence from the RAND Health Reform Opinion Study.

RAND's Health Reform Opinion Study (HROS) allows for an estimation of how many people have become enrolled in all sources of health care coverage since the implementation of the Affordable Care Act (ACA). The HROS is conducted using the RAND American Life Panel, a nationally representative panel of individuals who regularly participate in surveys; this particular analysis, is focused on respondents age 18-64. In addition to asking them about their opinions of the ACA, each month RAND collected information about enrollment in health insurance, including employer-sponsored insurance (ESI), Medicaid, Medicare, insurance purchased on a marketplace, and other insurance purchased on the individual market. This detailed information about insurance coverage combined with the fact that the same individuals were surveyed each month provides a unique ability to track how insurance coverage has changed since the major health insurance coverage provisions of the ACA took effect on January 1, 2014. The analysis presented here examines changes in health insurance enrollment between September 2013 and March 2014; overall, the authors estimate that 9.3 million more people have health care coverage in March 2014, lowering the uninsured rate from 20.5 percent to 15.8 percent. This increase in coverage is driven not only by enrollment in health insurance marketplace plans, but also by gains in ESI and Medicaid. Enrollment in ESI plans increased by 8.2 million and Medicaid enrollment increased by 5.9 million, although some individuals did lose coverage during this period. The authors also found that 3.9 million people are now covered through the state and federal marketplaces-the so-called insurance exchanges-and less than 1 million people who previously had individual-market insurance became uninsured during the period in question. While the survey cannot tell if this latter group lost their insurance due to cancellation or because they simply felt the cost was too high, the overall number is very small, representing less than 1 percent of people between the ages of 18 and 64.