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.

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.

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.

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.

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.

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.

Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases.

STUDY OBJECTIVE: We assess whether the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) results in changes in emergency department (ED) visits or ED payer mix. We also test whether the size of the change in ED visits depends on the change in the size of the Medicaid population. METHODS: Using all-capture, longitudinal, state data from the Agency for Healthcare Research and Quality's Fast Stats program, we implemented a difference-in-difference analysis, which compared changes in ED visits per capita and the share of ED visits by payer (Medicaid, uninsured, and private insurance) in 14 states that did and 11 states that did not expand Medicaid in 2014. Analyses controlled for state-level demographic and economic characteristics. RESULTS: We found that total ED use per 1,000 population increased by 2.5 visits more in Medicaid expansion states than in nonexpansion states after 2014 (95% confidence interval [CI] 1.1 to 3.9). Among the visit types that could be measured, increases in ED visits were largest for injury-related visits and for states with the largest changes in Medicaid enrollment. Compared with nonexpansion states, in expansion states the share of ED visits covered by Medicaid increased 8.8 percentage points (95% CI 5.0 to 12.6), whereas the uninsured share decreased by 5.3 percentage points (95% CI -1.7 to -8.9). CONCLUSION: The ACA's Medicaid expansion has resulted in changes in payer mix. Contrary to other studies of the ACA's effect on ED visits, our study found that the expansion also increased use of the ED, consistent with polls of emergency physicians.

Public Response to Obamacare on Twitter.

BACKGROUND: The Affordable Care Act (ACA), often called "Obamacare," is a controversial law that has been implemented gradually since its enactment in 2010. Polls have consistently shown that public opinion of the ACA is quite negative. OBJECTIVE: The aim of our study was to examine the extent to which Twitter data can be used to measure public opinion of the ACA over time. METHODS: We prospectively collected a 10% random sample of daily tweets (approximately 52 million since July 2011) using Twitter's streaming application programming interface (API) from July 10, 2011 to July 31, 2015. Using a list of key terms and ACA-specific hashtags, we identified tweets about the ACA and examined the overall volume of tweets about the ACA in relation to key ACA events. We applied standard text sentiment analysis to assign each ACA tweet a measure of positivity or negativity and compared overall sentiment from Twitter with results from the Kaiser Family Foundation health tracking poll. RESULTS: Public opinion on Twitter (measured via sentiment analysis) was slightly more favorable than public opinion measured by the Kaiser poll (approximately 50% vs 40%, respectively) but trends over time in both favorable and unfavorable views were similar in both sources. The Twitter-based measures of opinion as well as the Kaiser poll changed very little over time: correlation coefficients for favorable and unfavorable public opinion were .43 and .37, respectively. However, we found substantial spikes in the volume of ACA-related tweets in response to key events in the law's implementation, such as the first open enrollment period in October 2013 and the Supreme Court decision in June 2012. CONCLUSIONS: Twitter may be useful for tracking public opinion of health care reform as it appears to be comparable with conventional polling results. Moreover, in contrast with conventional polling, the overall amount of tweets also provides a potential indication of public interest of a particular issue at any point in time.

Home and community-based service and other senior service use: Prevalence and characteristics in a national sample.

We report on the use of home and community-based services (HCBS) and other senior services and factors affecting utilization of both among Americans over age 60 in the Health and Retirement Study (HRS). Those using HCBS were more likely to be older, single, Black, lower income, receiving Medicaid, and in worse health. Past use of less traditional senior services, such as exercise classes and help with tax preparation, were found to be associated with current use of HCBS. These findings suggest use of less traditional senior services may serve as a "gateway" to HCBS that can help keep older adults living in the community.

Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage.

OBJECTIVES: To document how health insurance coverage changed for White, Black, and Hispanic adults after the Affordable Care Act (ACA) went into effect. METHODS: We used data from the American Community Survey from 2008 to 2014 to examine changes in the percentage of nonelderly adults who were uninsured, covered by Medicaid, or covered by private health insurance. In addition to presenting overall trends by race/ethnicity, we stratified the analysis by income group and state Medicaid expansion status. RESULTS: In 2013, 40.5% of Hispanics and 25.8% of Blacks were uninsured, compared with 14.8% of Whites. We found a larger gap in private insurance, which was partially offset by higher rates of public coverage among Blacks and Hispanics. After the main ACA provisions went into effect in 2014, coverage disparities declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites. Coverage gains were greater in states that expanded Medicaid programs. CONCLUSIONS: The ACA has reduced racial/ethnic disparities in coverage, although substantial disparities remain. Further increases in coverage will require Medicaid expansion by more states and improved program take-up in states that have already done so.

Health Literacy and Access to Care.

Despite well-documented links between low health literacy, low rates of health insurance coverage, and poor health outcomes, there has been almost no research on the relationship between low health literacy and self-reported access to care. This study analyzed a large, nationally representative sample of community-dwelling adults ages 50 and older to estimate the relationship between low health literacy and self-reported difficulty obtaining care. We found that individuals with low health literacy were significantly more likely than individuals with adequate health literacy to delay or forgo needed care or to report difficulty finding a provider, even after we controlled for other factors, including health insurance coverage, employment, race/ethnicity, poverty, and general cognitive function. They were also more likely to lack a usual source of care, although this result was only marginally significant after we controlled for other factors. The results show that in addition to any obstacles that low health literacy creates within the context of the clinical encounter, low health literacy also reduces the probability that people get in the door of the health care system in a timely way.

The insurance value of Medicare.

Medicare should provide access to care and protection from catastrophic spending while not being so generous that beneficiaries overconsume low-value care, thus driving up costs. Setting cost sharing is a balancing act that the Medicare program doesn't perform very well.

Health literacy and the digital divide among older Americans.

BACKGROUND: Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy. OBJECTIVE: The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older. DESIGN: We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans. PARTICIPANTS: Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users). MAIN MEASURES: Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and self-reported confidence filling out medical forms. KEY RESULTS: Only 9.7% of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9% of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95% CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95% CI 0.47 to 0.77]). CONCLUSION: Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide.

Assessing the Need for a New Household Panel Study: Health Insurance and Health Care.

This paper considers the availability of data for addressing questions related to health insurance and health care and the potential contribution of a new household panel study. The paper begins by outlining some of the major questions related to policy and concludes that survey data on health insurance, access to care, health spending, and overall economic well-being will likely be needed to answer them. The paper considers the strengths and weaknesses of existing sources of survey data for answering these questions. The paper concludes that either a new national panel study, an expansion in the age range of subjects in existing panel studies, or a set of smaller changes to existing panel and cross-sectional surveys, would significantly enhance our understanding of the dynamics of health insurance, access to health care, and economic well-being.

Essential health benefits and the Affordable Care Act: law and process.

Starting in 2014, the Affordable Care Act (ACA) will require private insurance plans sold in the individual and small-group markets to cover a roster of "essential health benefits." Precisely which benefits should count as essential, however, was left to the discretion of the Department of Health and Human Services (HHS). The matter was both important and controversial. Nonetheless, HHS announced its policy by posting on the Internet a thirteen-page bulletin stating that it would allow each state to define essential benefits for itself. On both substance and procedure, the move was surprising. The state-by-state approach departed from the uniform, federal standard that the ACA appears to anticipate and that informed observers expected HHS to adopt. And announcing the policy through an Internet bulletin appeared to allow HHS to sidestep traditional administrative procedures, including notice and comment, immediate review in the courts, and White House oversight. This article explores two questions. First, is the state-by-state approach a lawful exercise of HHS's authority? Second, did HHS in fact evade the procedural obligations that are meant to shape the exercise of its discretion?

Evaluating a novel online behavioural intervention to encourage cost-conscious strategies among US adults with chronic conditions who are enrolled in a high-deductible health plan: a proof-of-concept pilot study.

OBJECTIVES: Patients with chronic conditions enrolled in high-deductible health plans (HDHPs) face cost-related access barriers and high out-of-pocket spending. Our objectives were to develop a novel behavioural intervention to help HDHP enrollees with chronic conditions use cost-conscious strategies and evaluate the intervention's preliminary effectiveness, acceptability and feasibility. DESIGN: Prospective. SETTING: Online (USA). PARTICIPANTS: 36 US adults enrolled in an HDHP through their employer or an exchange with diabetes, hypertension, asthma, coronary artery disease and/or chronic obstructive pulmonary disease. 31/36 participants completed the study. INTERVENTION: We developed a 5-week intervention consisting of a website with educational modules on discussing costs with clinicians, saving for future healthcare costs, comparing healthcare prices and quality, preparing for appointments, following up after appointments and planning for future healthcare needs; and emails encouraging participants to access each module. OUTCOMES: We conducted a single-arm proof-of-concept pilot study of the intervention. Baseline and postintervention surveys measured primary outcomes of health insurance literacy and confidence in using cost-conscious strategies. 10 participants completed postintervention interviews. RESULTS: 31 (86%) participants completed a baseline and postintervention survey. Mean health insurance literacy scores (20-80 scale) improved from 56.5 to 67.1 (p<0.001). Mean confidence scores (0-10 scale) improved for talking to a healthcare provider about cost (6.1-7.6, p=0.0094), saving for healthcare (5.8-6.6, p=0.068), comparing prices (5.4-6.9, p=0.005) and comparing quality (6.1 to 7.6, p=0.0034). Participants found the website easy to use and helpful for learning about cost-conscious strategies on postintervention interviews. CONCLUSIONS: Our novel behavioural intervention was acceptable to HDHP enrollees with chronic conditions, feasible to deliver and associated with increased health insurance literacy and confidence in using cost-conscious strategies. This intervention should be tested in a definitive randomised controlled trial that is fully powered to evaluate its effects on cost-related access barriers, out-of-pocket spending and health outcomes in this growing patient population.

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.