Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults.

This study examines the association of partner Medicare Advantage plan status over 1 year with beneficiary and plan characteristics.

Developing an Adjunct Services Approach to Identify the Use of Procedures Not Covered by Health Insurance: The Case of In Vitro Fertilization.

BACKGROUND: Health care claims have an inherent limitation in that noncovered services are unreported. This limitation is particularly problematic when researchers wish to study the effects of changes in the insurance coverage of a service. In prior work, we studied the change in the use of in vitro fertilization (IVF) after an employer added coverage. To estimate IVF use before coverage began, we developed and tested an Adjunct Services Approach that identified patterns of covered services cooccurring with IVF. METHODS: Based on clinical expertise and guidelines, we developed a list of candidate adjunct services and used claims data after IVF coverage began to assess associations of those codes with known IVF cycles and whether any additional codes were also strongly associated with IVF. The algorithm was validated by primary chart review and was then used to infer IVF in the precoverage period. RESULTS: The selected algorithm included pelvic ultrasounds and either menotropin or ganirelix, yielding a sensitivity of 93.0% and specificity of >99.9%. DISCUSSION: The Adjunct Services Approach effectively assessed the change in IVF use postinsurance coverage. Our approach can be adapted to study IVF in other settings or to study other medical services experiencing coverage changes (eg, fertility preservation, bariatric surgery, and sex confirmation surgery). Overall, we find that an Adjunct Services Approach can be useful when (1) clinical pathways exist to define services delivered adjunct to the noncovered service, (2) those pathways are followed for most patients receiving the service, and (3) similar patterns of adjunct services occur infrequently with other procedures.

Helping Patients With Chronic Conditions Overcome Challenges of High-Deductible Health Plans: Mixed Methods Study.

BACKGROUND: A growing number of Americans are enrolled in high-deductible health plans (HDHPs). Enrollees in HDHPs, particularly those with chronic conditions, face high out-of-pocket costs and often delay or forgo needed care owing to cost. These challenges could be mitigated by the use of cost-conscious strategies when seeking health care, such as discussing costs with providers, saving for medical expenses, and using web-based tools to compare prices, but few HDHP enrollees engage in such cost-conscious strategies. A novel behavioral intervention could enable HDHP enrollees with chronic conditions to adopt these strategies, but it is unknown which intervention features would be most valued and used by this patient population. OBJECTIVE: This study aimed to assess preferences among HDHP enrollees with chronic conditions for a novel behavioral intervention that supports the use of cost-conscious strategies when planning for and seeking health care. METHODS: In an exploratory sequential mixed methods study among HDHP enrollees with chronic conditions, we conducted 20 semistructured telephone interviews and then surveyed 432 participants using a national internet survey panel. Participants were adult HDHP enrollees with diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or asthma. The interviews and survey assessed participants' health care experiences when using HDHPs and their preferences for the content, modality, and frequency of use of a novel intervention that would support their use of cost-conscious strategies when seeking health care. RESULTS: Approximately half (11/20, 55%) of the interview participants reported barriers to using cost-conscious strategies. These included not knowing where to find information and worrying that the use of cost-conscious strategies would be very time consuming. Most (18/20, 90%) interviewees who had discussed costs with providers, saved for medical expenses, or used web-based price comparison tools found these strategies to be helpful for managing their health care costs. Most (17/20, 85%) interviewees expressed interest in an intervention delivered through a website or phone app that would help them compare prices for services at different locations. Survey participants were most interested in learning to compare prices and quality, followed by discussing costs with their providers and putting aside money for care, through a website-based or email-based intervention that they would use a few times a year. CONCLUSIONS: Regular use of cost-conscious strategies could mitigate financial barriers faced by HDHP enrollees with chronic conditions. Interventions to encourage the use of cost-conscious strategies should be delivered through a web-based modality and focus on helping these patients in navigating their HDHPs to better manage their out-of-pocket spending.

THE IMPACT OF ELIGIBILITY FOR MEDICAID VERSUS SUBSIDIZED PRIVATE HEALTH INSURANCE ON MEDICAL SPENDING, SELF-REPORTED HEALTH, AND PUBLIC PROGRAM PARTICIPATION.

We use a regression discontinuity design to understand the impact of a sharp change in eligibility for Medicaid versus subsidized marketplace insurance at 138 percent of the federal poverty line on coverage, medical spending, health status, and other public program participation. We find a 5.5 percentage point shift from Medicaid to private insurance, with no net change in coverage. The shift increases individual health spending by $341 or 2 percent of income, with larger increases at higher points in the spending distribution. Two-thirds of the increase is from premiums and one-thirdfrom out-of-pocket medical spending. Self-rated health and other public program participation appear unchanged. We find no evidence of bunching below the eligibility threshold, which suggests either that individuals are willing to pay more for private insurance or that optimization frictions are high.

The Long-Run Prevalence of Food Insufficiency among Older Americans.

The prevalence of food insufficiency among seniors in any given year is well-documented, but the prevalence of this hardship over a longer time period in later life is unknown. Using panel data from the Health and Retirement Study, I find that about 8% of seniors report food insufficiency over a two-year recall window, while 22% experience it at some point over the two decades of their sixties and seventies. Food insufficiency is not concentrated among a small group of persistently disadvantaged elderly, but is instead a surprisingly common feature of the later life course.

Changes in Health Care Access and Utilization for Low-SES Adults Aged 51-64 Years After Medicaid Expansion.

OBJECTIVES: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults aged 51-64 years has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults aged 51-64 years before and after the ACA Medicaid expansion. METHODS: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N = 2,088 noninstitutionalized low-education adults aged 51-64 years (n = 633 in Medicaid expansion states, n = 1,455 in nonexpansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, and private), access (usual source of care, difficulty finding a physician, foregone care, cost-related medication nonadherence, and out-of-pocket costs), utilization (outpatient visit and hospitalization), and health status. RESULTS: Low-education adults aged 51-64 years had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in nonexpansion states, DID +7.4 pp, p = .001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in nonexpansion states, DID +10.4 pp, p = .003) in Medicaid expansion compared with nonexpansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in nonexpansion states (+3.6 pp in expansion states, +11.0 pp in nonexpansion states, DID -7.5 pp, p = .006). There were no other significant differences in access, utilization, or health trends between expansion and nonexpansion states. DISCUSSION: After Medicaid expansion, low-education status adults aged 51-64 years were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.

Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans.

Importance: Health savings accounts (HSAs) can be used by enrollees in high-deductible health plans (HDHPs) to save for health care expenses before taxes. Expansion of and encouraging contributions to HSAs have been centerpieces of recent federal legislation. Little is known about how US residents who may be eligible for HSAs are using them to save for health care. Objective: To determine which patients who may be eligible for an HSA do not have one and what decisions patients with HSAs make about contributing to them. Design, Setting, and Participants: This cross-sectional national survey assessed an online survey panel representative of the US adult population. Adults aged 18 to 64 years and enrolled in an HDHP for at least 12 months were eligible to participate. Data were collected from August 26 to September 19, 2016, and analyzed from November 1, 2019, to April 30, 2020. Main Outcomes and Measures: Prevalence of not having an HSA or not making HSA contributions in the last 12 months and reasons for not making the HSA contributions. Results: Based on data from 1637 individuals (American Association of Public Opinion Research response rate 4, 54.8%), half (50.6% [95% CI, 47.7%-53.6%]) of US adults in HDHPs were female, and most were aged 36 to 51 (35.7% [95% CI, 32.8%-38.6%]) or 52 to 64 (36.8% [95% CI, 34.1%-39.5%]) years. Approximately 1 in 3 (32.5% [95% CI, 29.8%-35.3%]) did not have an HSA. Those who obtained their health insurance through an exchange were more likely to lack an HSA (70.3% [95% CI, 61.9%-78.6%]) than those who worked for an employer that offered only 1 health insurance plan (36.5% [95% CI, 30.9%-42.1%]; P < .001). More than half of individuals with an HSA (55.0% [95% CI, 51.1%-58.8%]) had not contributed money into it in the last 12 months. Among HDHP enrollees with an HSA, those with at least a master's degree (46.1% [95% CI, 38.3%-53.9%]; P = .02) or a high level of health insurance literacy (47.3% [95% CI, 40.7%-54.0%]; P = .03) were less likely to have made no HAS contributions. Common reasons for not contributing to an HSA included not considering it (36.8% [95% CI, 30.8%-42.8%]) and being unable to afford saving for health care (31.9% [95% CI, 26.2%-37.6%]). Conclusions and Relevance: These findings suggest that many US adults enrolled in an HDHP lack an HSA, and few with an HSA saved for health care in the last year. Targeted interventions should be explored by employers, health plans, and health systems to encourage HSA uptake and contributions among individuals who could benefit from their use.

The ACA's Impact On Racial And Ethnic Disparities In Health Insurance Coverage And Access To Care.

Large disparities in health insurance coverage and access to health services have long persisted in the US health care system. We considered how the insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups. Because coverage increased more for non-Hispanic blacks and Hispanics than for non-Hispanic whites, disparities in coverage have decreased. Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites.

Macroeconomic Feedback Effects of Medicaid Expansion: Evidence from Michigan.

CONTEXT: Medicaid expansion has costs and benefits for states. The net impact on a state's budget is a central concern for policy makers debating implementing this provision of the Affordable Care Act. How large is the state-level fiscal impact of expanding Medicaid, and how should it be estimated? METHODS: We use Michigan as a case study for evaluating the state-level fiscal impact of Medicaid expansion, with particular attention to the importance of macroeconomic feedback effects relative to the more straightforward fiscal effects typically estimated by state budget agencies. We combine projections from the state of Michigan's House Fiscal Agency with estimates from a proprietary macroeconomic model to project the state fiscal impact of Michigan's Medicaid expansion through 2021. FINDINGS: We find that Medicaid expansion in Michigan yields clear fiscal benefits for the state, in the form of savings on other non-Medicaid health programs and increases in revenue from provider taxes and broad-based sales and income taxes through at least 2021. These benefits exceed the state's costs in every year. CONCLUSIONS: While these results are specific to Michigan's budget and economy, our methods could in principle be applied in any state where policy makers seek rigorous evidence on the fiscal impact of Medicaid expansion.

Changes in Veterans' Coverage and Access to Care Following the Affordable Care Act, 2011-2017.

Objectives. To evaluate the effect of the Affordable Care Act (ACA) on US veterans' access to care.Methods. We used US Behavioral Risk Factor Surveillance System data to compare measures of veterans' coverage and access to care, including primary care, for 3-year periods before (2011-2013) and after (2015-2017) ACA coverage provisions went into effect. We used difference-in-differences analyses to compare changes in Medicaid expansion states with those in nonexpansion states.Results. Coverage increased and fewer delays in care were reported in both expansion and nonexpansion states after 2014, with larger effects among low socioeconomic status (SES) and poor health subgroups. Coverage increases were significantly larger in expansion states than in nonexpansion states. Reports of cost-related delays, no usual source of care, and no checkup within 12 months generally improved in expansion states relative to nonexpansion states, but improvements were small; changes were mixed among veterans with low SES or poor health.Conclusions. Increases in insurance coverage among nonelderly veterans after ACA coverage expansions did not consistently translate into improved access to care. Additional study is needed to understand persisting challenges in veterans' access to care.

A Survey Of Americans With High-Deductible Health Plans Identifies Opportunities To Enhance Consumer Behaviors.

Most high-deductible health plan (HDHP) enrollees do not engage in consumer behaviors such as price shopping. Why not? We surveyed 1,637 Americans in HDHPs-which can be linked to health savings accounts (HSAs) but usually are not-about factors that may predict, facilitate, or impede HDHP enrollees' engagement in consumer behaviors. We found that having an HSA was associated with saving for future care, high financial literacy was associated with comparing prices and quality, and high confidence in talking with providers about costs and trying to negotiate prices was associated with engaging in these behaviors. Employer HSA contributions were the most frequent facilitator of saving, websites were the most frequent facilitators of comparing prices and quality, and "someone at the doctor's office" was the most frequent facilitator of discussing costs with providers and trying to negotiate prices. The most frequent impediment to all of these behaviors was not having considered them when making decisions. These results suggest strategies that health plans, employers, and health systems should explore to promote greater engagement in consumer behaviors among patients in HDHPs.

Does Home Equity Affect Decisions on Long-Term Care Insurance Purchases? Evidence From the United States.

The low uptake of private long-term care insurance (LTCI) by the elderly in the United States, despite visible risks, has left economists puzzled. Prior studies have hypothesized that home equity can be a substitute for LTCI and hence may partly explain the low uptake. We test this hypothesis empirically. We utilize exogenous variation in house prices at the level of the metropolitan statistical area (MSA) as an instrument for home equity for individuals residing in that MSA and data from the Health and Retirement Study. In the most robust specifications, we find no evidence that the elderly change their decision on LTCI based on variation in their home equity, and even specifications requiring stronger identification assumptions imply only small effect magnitudes. Home equity as a substitute for LTCI does not appear to be a major contributing factor to low LTCI take up.

Attitudes About Consumer Strategies Among Americans in High-deductible Health Plans.

BACKGROUND: More than 70 million Americans are enrolled in a high-deductible health plan (HDHP), with high upfront cost-sharing to encourage strategies such as price shopping to mitigate out-of-pocket spending. Recent research suggests HDHP enrollees are reluctant to engage in these consumer strategies, but there is little information on why. OBJECTIVES: To describe associations between HDHP enrollees' attitudes about and intent to engage in consumer strategies. RESEARCH DESIGN: We conducted a nationally representative web survey of 1637 HDHP enrollees that included 2 hypothetical scenarios amenable to consumer strategies. For each scenario, we asked participants whether they would compare price or quality information, discuss cost with a provider, or try to negotiate a service price. We measured participants' ratings of the difficulty of each strategy, its effectiveness at reducing cost or increasing the likelihood of getting care, and how likely participants would be to actually engage in each strategy. RESULTS: Fewer than half of HDHP enrollees intended to engage in any of the surveyed strategies. Enrollees who viewed a consumer strategy as helpful were more likely to engage in that strategy; no associations were found with perceived difficulty of a strategy and intent to engage in it. CONCLUSIONS: HDHP enrollees may not pursue consumer strategies because they believe they are not helpful for getting care or lowering costs. Providers and payers should ensure these strategies are actually helpful to HDHP enrollees and that enrollees understand how they could use these strategies to reduce their out-of-pocket costs.

Determinants of Hearing Aid Use Among Older Americans With Hearing Loss.

BACKGROUND AND OBJECTIVES: Hearing loss (HL) is common among older adults and is associated with significant psychosocial, cognitive, and physical sequelae. Hearing aids (HA) can help, but not all individuals with HL use them. This study examines how social determinants may impact HA use. RESEARCH DESIGN AND METHODS: We conducted an explanatory sequential mixed methods study involving a secondary analysis of a nationally representative data set, the Health and Retirement Study (HRS; n = 35,572). This was followed up with 1:1 qualitative interviews (n = 21) with community participants to clarify our findings. Both samples included individuals aged 55 and older with a self-reported HL, with or without HA. The main outcome measure was the proportion of participants with a self-reported HL who use HA. RESULTS AND DISCUSSION: Analysis of HRS data indicated that younger, nonwhite, non-Hispanic, lower income, and less-educated individuals were significantly less likely to use HA than their referent groups (all p values < .001). Area of residence (e.g., urban) were not significantly associated with HA use. Qualitative findings revealed barriers to HA included cost, stigma, vanity, and a general low priority placed on addressing HL by health care providers. Facilitators to obtaining and using HA included family/friend support, knowledge, and adequate insurance coverage for HA. IMPLICATIONS: Many socioeconomic factors hinder individuals' ability to obtain and use HA, but these obstacles appeared to be mitigated in part when insurance plans provided adequate HA coverage, or when their family/friends provided encouragement to use HA.

Racial and Ethnic Disparities in the Lifetime Prevalence of Homelessness in the United States.

Homelessness in the United States is often examined using cross-sectional, point-in-time samples. Any experience of homelessness is a risk factor for adverse outcomes, so it is also useful to understand the incidence of homelessness over longer periods. We estimate the lifetime prevalence of homelessness among members of the Baby Boom cohort (n = 6,545) using the 2012 and 2014 waves of the Health and Retirement Study (HRS), a nationally representative survey of older Americans. Our analysis indicates that 6.2 % of respondents had a period of homelessness at some point in their lives. We also identify dramatic disparities in lifetime incidence of homelessness by racial and ethnic subgroups. Rates of homelessness were higher for non-Hispanic blacks (16.8 %) or Hispanics of any race (8.1 %) than for non-Hispanic whites (4.8 %; all differences significant with p < .05). The black-white gap, but not the Hispanic-white gap, remained significant after adjustment for covariates such as education, veteran status, and geographic region.

Tobacco Regulation and Cost-Benefit Analysis: How Should We Value Foregone Consumer Surplus?

Recent tobacco regulations proposed by the Food and Drug Administration have raised a thorny question: how should the cost-benefit analysis accompanying such policies value foregone consumer surplus associated with regulation-induced reductions in smoking? In a model with rational and fully informed consumers, this question is straightforward. There is disagreement, however, about whether consumers are rational and fully informed, and the literature offers little practical guidance about what approach the FDA should use if they are not. In this paper, we outline the history of the FDA's recent attempts to regulate cigarettes and other tobacco products and how they have valued foregone consumer surplus in cost-benefit analyses. We advocate replacing the approach used in most of this literature, which first calculates health gains associated with regulation and then "offsets" them by some factor reflecting consumer surplus losses, with a more general behavioral public finance framework for welfare analysis. This framework applies standard tools of welfare analysis to consumer demand that may be "biased" (that is, not necessarily rational and fully informed) without requiring specific assumptions about the reason for the bias. This framework would require estimates of both biased and unbiased consumer demand; we sketch an agenda to help develop these in the context of smoking. The use of this framework would substantially reduce the confusion currently surrounding welfare analysis of tobacco regulation.

Health Reform and Retirement.

Objective: To analyze whether there was an increase in retirement or in part-time work among older workers after January 2014, when new health insurance coverage options became available because of the Affordable Care Act (ACA). Method: We analyze trends in retirement and part-time work for individuals aged 50-64 years in the basic monthly Current Population Survey from January 2008 through June 2016. We test for a break in trend in January 2014. We also test for differences in trends, both before and after 2014, in states that expanded their Medicaid programs in January 2014 under the ACA compared with those that did not. Results: We find that there was no change in the probability of retirement or part-time work among older workers in 2014 and later, either overall or in Medicaid expansion states relative to nonexpansion states. Discussion: Although many observers had predicted that an unintended consequence of health reform would be reduced labor supply, we find no evidence of this for older workers in the first 2.5 years after the law's major coverage provisions took effect.