Gains in insurance coverage following the affordable care act and change in preventive services use among non-elderly US immigrants.

Immigrants have lower and disproportionate use of preventive care. We use longitudinal panel data to examine how the 2014 full implementation of the ACA mandates affected change in preventive services (PS) use among immigrants that gained insurance. We used data on Foreign-Born (FB) and US-Born (USB) adults, ages 26-64 years, from the 2013/16 Medical Expenditures Panel Survey longitudinal files to examine within-person change in yearly utilization of age/sex specific United States Preventive Services Task Force (USPSTF) recommended services. We included five primary care (e.g., influenza immunization), three behavioral (e.g., diet), and seven cancer screening (e.g., mammography) measures. We used generalized estimating equations and difference-in-differences tests to assess the effects of insurance gain on: (1) change in PS utilization, and (2) reduction in utilization disparities between USB and FB adults, adjusting for predisposing, health enabling, and health needs factors. Our results showed that newly-insured FB adults substantially increased their use of all primary care checks, and exercise and diet advice. We also found improvements in use of endoscopies, two modalities of colon cancer screening, and prostate cancer screening, but not in receipt of mammography and clinical breast exams. Newly-insured FB PS use remained lower than use among continuously-insured USB adults, but some of the differences were explained by adjustment to enabling and health needs factors. Briefly, health insurance gains among immigrants translated into substantial improvements in use of recommended PS. Still, notable disparities persist among the newly-insured FB, and more so among the 1 in 5 that remain continuously uninsured.

Effects of the Affordable Care Act's enhancement of Medicare benefits on preventive services utilization among older adults in the U.S.

Since 2011, the Affordable Care Act (ACA) requires the provision of certain recommended clinical preventive services without cost-sharing for individuals in Medicare. We re-visited the effects of the ACA on preventive services utilization under Medicare, using data from the Medical Expenditure Panel Survey (MEPS) and examined the ACA's longer-term effects on preventive services utilization among Medicare beneficiaries. We analyzed nationally representative data on non-institutionalized Medicare beneficiaries (n = 27,124) from the 2006-2010 and 2012-2016 Medical Expenditure Panel Survey. Preventive services of interest were cholesterol test, blood pressure test, flu shot, endoscopy, blood stool test, clinical breast exam, mammography and prostate exam. We estimated propensity score weighted difference-in-difference (DID) models to test for differences in preventive services utilization based on Medicare insurance status. Nationwide, among beneficiaries with traditional Medicare only, who stood to gain the most from eliminating cost-sharing for preventive services, the percentage of women receiving clinical breast exams rose post-reform (Δ = 8.1%; p < 0.015) as compared to Medicare beneficiaries with supplemental private coverage, while at the same time the percentage receiving other preventive services did not change post-reform (all p > 0.05). Based on this analysis of MEPS data spanning 2006-2016, the ACA's enhancement of Medicare coverage had only modest effects on the percentage of beneficiaries receiving a range of preventive services. Medicare beneficiaries should be better informed of the availability of these services and encouraged by their physicians to avail the no cost-sharing incentive of these reforms.

A slow start: Use of preventive services among seniors following the Affordable Care Act's enhancement of Medicare benefits in the U.S.

OBJECTIVE: Beginning January 1st, 2011 in the United States the Affordable Care Act enhanced Medicare coverage for preventive services by eliminating patient cost-sharing under Part B and by introducing an "Annual Wellness Visit," also free-of-charge. We evaluated the early effects of these reforms on utilization of preventive services. METHOD: We analyzed nationally representative data on 15,044 Medicare seniors from the 2008-2010, and 2012 Medical Expenditure Panel Survey, and examined self-reported cholesterol test, blood pressure check, flu vaccination, endoscopy, fecal occult blood test, prostate specific antigen test, breast examination, and mammography. RESULTS: Enhanced Medicare benefits had no effects on preventive service utilization among Medicare seniors in 2012, including those with traditional Medicare and no other supplemental insurance, who stood to benefit the most from Part B enhancements. CONCLUSION: The muted overall response can be partly attributed to the fact that most seniors already held insurance that fully covered preventive services. While insurance enhancements can sometimes raise utilization, in the case of preventive services there are other fundamental barriers that require attention. Educating and incentivizing physicians about the need to refer/recommend screenings, and enhancing knowledge among seniors about the importance of preventive care are two steps that would likely go a long way towards increasing utilization.

Pricing distortions in Medicare's physician fee schedule and patient satisfaction with care quality and access.

Medicare adjusts its payments to physicians for geographic differences in the cost of operating a medical practice, but the method it uses is imprecise. We measure the inaccuracy in its geographic adjustment factors and categorize beneficiaries by whether they live where Medicare's formula is favorable or unfavorable to physicians. Then, using the 2001-2003 Medicare Current Beneficiary Survey, we examine whether differences in physician payment generosity, that is, whether favorable or unfavorable, influence the satisfaction ratings Medicare seniors assign to their quality of care and access to services. We find strong evidence that they do. Many beneficiaries live in payment-unfavorable areas and receive a less satisfying quality of care and less satisfying access to services than beneficiaries who live where payments are favorable to physicians.

Payment generosity and physician acceptance of Medicare and Medicaid patients.

Using 2008 physician survey data, we estimate the relationship between the generosity of fees paid to primary care physicians under Medicaid and Medicare and his/her willingness to accept new patients covered by Medicaid, Medicare, or both programs (i.e., dually enrolled patients). Findings reveal physicians are highly responsive to fee generosity under both programs. Also, their willingness to accept patients under either program is affected by the generosity of fees under the other program, i.e., there are significant spillover effects between Medicare and Medicare fee generosity. We also simulate how physicians in 2008 would have likely responded to Medicaid and Medicare payment reforms similar to those embodied in the 2010 Affordable Care Act, had they been permanently in place in 2008. Our findings suggest that "Medicaid Parity" for primary care physicians would have likely dramatically improved physician willingness to accept new Medicaid patients while only slightly reducing their willingness to accept new Medicare patients. Also, many more primary care physicians would have been willing to treat dually enrolled patients.

Diverging racial and ethnic disparities in access to physician care: comparing 2000 and 2007.

OBJECTIVE: To examine recent changes in racial and ethnic disparities in access to physician services in the United States, and investigate the economic factors driving the changes observed. METHODS: Using nationally representative data on adults aged 25-64 from the 2000 and 2007 Medical Expenditure Panel Survey, we examine changes in two measures of access: whether the individual reported having a usual source of care, and whether he/she had any doctor visits during the past year. In each year, we calculate disparities in access between African Americans and Whites, and between Hispanics and Whites, applying the Institute of Medicine's definition of a disparity. Nonlinear regression decomposition techniques are then used to quantify how changes in personal characteristics, comparing 2000 and 2007, helped shape the changes observed. RESULTS: Large disparities in access to physician care were evident for both minority groups in 2000 and 2007. Disparities in no doctor visits during the past year diminished for African Americans, but disparities in both measures worsened sharply for Hispanics. CONCLUSIONS: Disparities in access to physician care are improving for African Americans in one dimension, but eroding for Hispanics in multiple dimensions. The most important contributing factors to the growing disparities between Hispanics and Whites are health insurance, education, and income differences.

The impact of private long-term care insurance on the use of long-term care.

This paper investigates the effects of privately purchased long-term care insurance (LTCI) on three major types of long-term care services: nursing home care, paid home care, and informal care received from Family and friends. Using 2002-2008 data from the ongoing Health and Retirement Study, we analyze the determinants of long-term care utilization simultaneously with the determinants of holding LTCI. We find that LTCI has modest effects on the likelihood of using long-term care services. For the very frail elderly, private LTCI enhances their access to nursing home care. For those with moderate disability, LTCI makes it more likely that they can remain at home and receive home care services, instead of going to a nursing home. We find no evidence that formal care substitutes for informal care in the presence of LTCI. These findings suggest that if LTCI becomes much more prevalent in the future, many older adults will be able to choose the type of long-term care arrangement that best suits their needs.

Racial/Ethnic Differences in Mortality in Late Midlife: Have They Narrowed in Recent Years?

OBJECTIVES: To examine whether racial/ethnic differences in mortality rates have changed in recent years among adults in late midlife, and if so, how. METHODS: We analyze Health and Retirement Study data on non-Hispanic Whites (Whites), non-Hispanic Blacks (Blacks), and English- and Spanish-speaking Hispanics (Hispanic-English and Hispanic-Spanish), aged 50-64 from 2 periods: 1998-2004 (Period 1, n = 8,920) and 2004-2010 (Period 2, n = 7,224). Using survey-generalized linear regression techniques, we model death-by-end-of-period as a function of race/ethnicity and sequentially adjust for a series of period-specific baseline risk factors including demographics, health status, health insurance, health behaviors, and social networks. Regression decomposition techniques are used to assess the contribution of these factors to observed racial/ethnic differences in mortality rates. RESULTS: The odds ratio for death (ORD) was not statistically different for Blacks (vs. Whites) in Period 1 but was 33% higher in Period 2 (OR = 1.33; 95% confidence interval [CI] = 1.05-1.69). The adjusted ORD among Hispanic-English (vs. Whites) was not statistically different in both periods. The adjusted ORD among Hispanic-Spanish (vs. Whites) was lower (ORD = 0.36; 95% CI = 0.22-0.59) in Period 1 but indistinguishable in Period 2. In Period 1, 50.1% of the disparity in mortality rates among Blacks was explained by baseline health status, 53.1% was explained by financial factors. In Period 2, 55.8% of the disparity in mortality rates was explained by health status, 40.0% by financial factors, and 16.2% by health insurance status. DISCUSSION: Mortality rates among Blacks and Hispanic-Spanish have risen since the mid-1990s. Hispanic-Spanish may be losing their advantageous lower risk of mortality, long known as the "Hispanic Paradox."

Changes in Insurance Coverage and Healthcare Use Among Immigrants and US-Born Adults Following the Affordable Care Act.

OBJECTIVES: Immigrants to the USA have disparate access to health insurance coverage and healthcare services. We evaluate the effects of gaining insurance following the January 2014 Affordable Care Act's (ACA) key provisions implementation on health services use among foreign- (FB) and US-born (USB) adults. METHODS: Longitudinal data from two panels (2013/2014 and 2014/2015) of the Medical Expenditure Panel Survey on FB and USB adults, ages 26-64 (unweighted n = 15,232), and difference-in-differences analysis using generalized estimating equations were used to estimate the effects of insurance gain. The primary outcomes were five measures of healthcare utilization including yearly routine care appointment, annual number of physician office visits, annual number of prescription medications filled or refilled, use of the emergency department (ED) during the year, and having an inpatient hospital stay during the year. RESULTS: Immigrants were more likely to gain health insurance between 2013 and 2015 relative to USB adults (6.3% vs. 4.4%) but remained much more likely to be continuously uninsured by 2015 (20.8% vs. 6.4%). Controlling for sociodemographic and health characteristics, FB and USB adults who gained insurance increased their use of health services, including routine care (absolute change ΔFB = 15.7%; p < 0.001 and ΔUSB = 11.7%; p < 0.001), office-based doctor visits (ΔFB = 1.3; p < 0.001 and ΔUSB = 0.6; p < 0.001), prescribed medications (ΔFB = 2.5; p < 0.001 and ΔUSB = 1.6; p = 0.016), and inpatient hospitalizations (ΔFB = 3.6%; p = 0.017 and ΔUSB = 3%; p < 0.001). ED use increased only among the FB (ΔFB = 4.8%; p < 0.001). Gaining insurance eliminated the differences in health services use for all considered outcomes among the FB relative to the continuously insured USB. CONCLUSIONS: US immigrants had notable gains in health insurance after the ACA provisions took full effect, but major disparities in coverage persist. If insurance continues to expand among immigrants, then the gains may reduce longstanding disparities in health services use and enhance primary and preventive healthcare.

Medicare Part B reimbursement and the perceived quality of physician care.

The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor's care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians' ability to balance bill significantly reduce the perceived quality of care under Part B.

Medicaid managed care and preventable emergency department visits in the United States.

OBJECTIVES: In the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use. METHODS: Using data from the 2003-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting. RESULTS: We found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy. CONCLUSIONS: Within the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care.

Trajectories of Aging Among U.S. Older Adults: Mixed Evidence for a Hispanic Paradox.

OBJECTIVES: A well-documented paradox is that Hispanics tend to live longer than non-Hispanic Whites (NHW), despite structural disadvantages. We evaluate whether the "Hispanic paradox" extends to more comprehensive longitudinal aging classifications and examine how lifecourse factors relate to these groupings. METHODS: We used biennial data (1998-2014) on adults aged 65 years and older at baseline from the Health and Retirement Study. We use joint latent class discrete time and growth curve modeling to identify trajectories of aging, and multinomial logit models to determine whether U.S.-born (USB-H) and Foreign-born (FB-H) Hispanics experience healthier styles of aging than non-Hispanic Whites (NHW), and test how lifecycle factors influence this relationship. RESULTS: We identify four trajectory classes including, "cognitive unhealthy," "high morbidity," "nonaccelerated", and "healthy." Compared to NHWs, both USB-H and FB-H have higher relative risk ratios (RRR) of "cognitive unhealthy" and "high morbidity" classifications, relative to "nonaccelerated." These patterns persist upon controlling for lifecourse factors. Both Hispanic groups, however, also have higher RRRs for "healthy" classification (vs "nonaccelerated") upon adjusting for adult achievements and health behaviors. DISCUSSION: Controlling for lifefcourse factors USB-H and FB-H have equal or higher likelihood for "high morbidity" and "cognitive unhealthy" classifications, respectively, relative to NHWs. Yet, both groups are equally likely of being in the "healthy" group compared to NHWs. These segregations into healthy and unhealthy groups require more research and could contribute to explaining the paradoxical patterns produced when population heterogeneity is not taken into account.

Is enrollment in a Medicaid health maintenance organization associated with less preventable hospitalizations?

INTRODUCTION: The objective of this study is to compare the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the prevalence of potentially preventable hospitalizations, a recognized measure of outpatient care quality. METHODS: This study used nationally representative data on non-institutionalized Medicaid recipients, ages 18-64, from the 2003-2012 Medical Expenditure Panel Survey. Separate analyses are conducted for recipients insured through both Medicaid and Medicare ("dual eligibles") and recipients whose only health insurance is Medicaid ("non-duals"). In each group the occurrence of potentially preventable hospitalizations is measured, and then survey-weighted multivariable logistic regression models are fit to quantify the relationship between Medicaid HMO status and the occurrence of such stays. The possibility of selection bias into HMOs is considered and explicitly addressed in model estimation using propensity score methods. RESULTS: Adjusting for covariates and confounders dual eligible enrolled in Medicaid managed care are more likely to have a potentially preventable hospitalization relative to those covered under FFS Medicaid (survey weighted logit model OR = 1.72, 95% CI = 0.98-3.03; propensity score weighted logit model OR = 1.87, 95% CI = 1.06-3.28). In contrast, the odds ratios did not differ among non-duals in Medicaid HMOs versus FFS Medicaid. CONCLUSION: These findings suggest that, at least for dual eligibles, the quality of outpatient care in Medicaid HMOs may be worse than under FFS Medicaid. Better and more streamlined clinical preventive approaches for this high risk and vulnerable population might be required in Medicaid HMOs.

Health Shocks and Initiation of Use of Preventive Services Among Older Adults.

This article examines whether adverse changes to health or functioning serve as an impetus to begin using preventive services among older individuals with a history of non-use. Using data from the 1998-2008 Health and Retirement Study, the use of mammograms, pap smears, prostate cancer screenings, cholesterol checks, and flu shots is examined among 2,975 self-reported non-users of such services. Older women who experience a health shock are 1.86, 1.50, 1.79, and 1.46 times more likely to begin getting mammograms, pap smears, cholesterol checks, and flu shots, respectively. Older men who experience a health shock are 2.24, 2.72, and 1.64 times more likely to begin getting prostate cancer screenings, cholesterol checks, and flu shots, respectively. All of these results are statistically significant. Thus, older adults often improve their health behaviors after experiencing an adverse health event.

Healthy Aging After Age 65: A Life-Span Health Production Function Approach.

This article examines the determinants of healthy aging using Grossman's framework of a health production function. Healthy aging, sometimes described as successful aging, is produced using a variety of inputs, determined in early life, young adulthood, midlife, and later life. A healthy aging production function is estimated using nationally representative data from the 2010 and 2012 Health and Retirement Study on 7,355 noninstitutionalized seniors. Using a simultaneous equation mediation model, we quantify how childhood factors contribute to healthy aging, both directly and indirectly through their effects on mediating adult outcomes. We find that favorable childhood conditions significantly improve healthy aging scores, both directly and indirectly, mediated through education, income, and wealth. We also find that good health habits have positive effects on healthy aging that are larger in magnitude than the effects of childhood factors. Our findings suggest that exercising, maintaining proper weight, and not smoking are likely to translate into healthier aging.

Effects of Medicare Coverage of a "Welcome-to-Medicare" Visit on Use of Preventive Services among New Medicare Enrollees.

In January 2005, Medicare began covering a one-time initial preventive physical examination (IPPE), also called a "Welcome-to-Medicare" visit, during a beneficiary's first 6 months under Part B. This paper examines the effects of offering Medicare IPPE coverage on the use of mammograms, breast self-exams, Pap smears, prostate cancer screenings, cholesterol screenings, and flu vaccines among beneficiaries new to Part B. We adopt a difference-in-difference estimator and estimate a set of multivariate logit models to quantify the effects of introducing Medicare IPPE coverage on the use of preventive services. Models are estimated separately for men and women. Data for the analysis come from the 1996-2008 Health and Retirement Study. Among both men and women, having coverage for a one-time IPPE under Medicare had no effects on the utilization of any of the preventive services listed above. In this study, we find that offering coverage for a one-time IPPE under Medicare was insufficient to spur greater use of preventive services among new Medicare beneficiaries. These findings are important and suggest that policy-makers may need to consider other approaches to increase the use of recommended preventive services.

Why don't people buy long-term-care insurance?

OBJECTIVES: The objective of this article was to assess the determinants of an individual's decision to purchase long-term-care (LTC) insurance. This article focuses on the decision to purchase a new policy as opposed to renewing an existing policy. This study gave special consideration to the role of policy price, the savings associated with buying a policy now as opposed to later, the purchaser's education, and the purchaser's income. METHODS: Using data from the 2002 Health and Retirement Survey, we estimated logistic regressions to model consumer decisions to purchase LTC insurance. We explored several alternative measures of the price of a policy. RESULTS: Price was a significant determinant in decisions to purchase coverage. The demand for coverage, however, was price inelastic, with elasticities ranging from -0.23 to -0.87, depending on the specification of the model. The education level and income of the purchaser were also important. DISCUSSION: This analysis provides the first estimates of price elasticity of demand for LTC insurance. The finding that demand is very price inelastic suggests that state initiatives that effectively subsidize premiums as a way of stimulating purchases are likely to meet with very limited success in the present environment.

Health effects of managed care among the near-elderly.

OBJECTIVE: The authors evaluate whether enrolling in a health maintenance organization (HMO) or preferred provider organization (PPO) affects the health of adults ages 55 to 64, relative to fee-for-service plans. METHODS: A nationwide random sample of 4,044 adults with employer-sponsored health insurance is drawn from the 1994 to 2000 waves of the Health and Retirement Study. Multinomial logit regressions are estimated for self-reported general health status, first using a sample of all near-elders, then using subsamples of near-elders with and without longstanding chronic health conditions. The possibility of selection bias into managed care plans is considered and explicitly addressed in model estimation. RESULTS: We find no ill effects of HMOs on health status, and older adults with a history of chronic health conditions actually fare better upon enrolling in these plans. DISCUSSION: More research is needed to understand the reasons for the observed beneficial effects of managed care.

Impact of Medicare Age Eligibility on Health Spending among U.S. and Foreign-Born Adults.

OBJECTIVE: Examine differences in health care expenditures between foreign-born and U.S.-born adults in late mid-life, and how these differences change after age 65, when Medicare is near-universal. DATA: Medical Expenditures Panel Survey data (2000-2010) on adults ages 55-75 years (n = 46,132) to examine annual total and payer-specific expenditures. STUDY DESIGN: We use (1) propensity score matching to generate quasi-experimental samples with equivalent health needs and health care preferences, (2) generalized linear modeling to estimate group differences in expenditures, and (3) bootstrapping methods to obtain variance estimates for significance testing. PRINCIPAL FINDINGS: Among adults ages 55-64, the foreign-born spend $3,314 (p < .001) less on health care, even when they have equivalent health needs and health care preferences. This difference is due mainly to lower spending through private insurance. After age 65, differences in total spending disappear but not differences in payer-specific spending. The foreign-born continue to spend significantly less through private insurance and begin to spend significantly more through Medicare and Medicaid. CONCLUSION: Foreign-born adults in late mid-life spend significantly less on health care than U.S.-born adults. After age 65, with near-universal Medicare coverage, differences in total spending disappear between the groups, although differences in spending by payer persist.