Association of Medicaid Expansion With Quality in Safety-Net Hospitals.

Importance: Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown. Objective: To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not. Design, Setting, and Participants: Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020. Exposures: Time-varying indicators for Medicaid expansion status. Main Outcomes and Measures: The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care). Results: In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001). Conclusions and Relevance: This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.

Impact of the affordable care act's medicaid expansion on burn outcomes and disposition.

BACKGROUND: We aimed to analyze the impact of the Affordable Care Act's Medicaid Expansion on clinical outcomes and patient disposition after burn injury. We hypothesized that increased insurance coverage results in improved outcomes and higher rates of discharge to inpatient rehabilitation. METHODS: We reviewed the University of Washington Regional Burn Center registry data for patients admitted from 2011 to 2018. Patients were grouped into two categories: before (2011-2013) and after (2015-2018) Medicaid expansion; we excluded 2014 data to serve as a washout period. Outcomes assessed included length of hospital stay, patient disposition, and mortality. Multivariable logistic and linear regression models with covariates for sex, age, burn size, ethnicity ethnicity, distance from burn center, etiology of burn, and presence of inhalation injury were used to determine the impact of Medicaid expansion on outcomes. RESULTS: Rates of uninsured patients decreased while Medicaid coverage increased. Despite increased median burn size after Medicaid expansion, inpatient mortality rates did not change, but average acute care length of stay increased. More patients were discharged to rehabilitation centers. CONCLUSIONS: Our study corroborates prior findings of increased insurance coverage since Medicaid expansion. Increased insurance coverage is associated with higher rates of discharge to inpatient rehabilitation programs after burn injury.

Portals of Change: How Patient Portals Will Ultimately Work for Safety Net Populations.

Despite the implementation of internet patient portals into the safety net after the introduction of the Affordable Care Act in the United States, little attention has been paid to the process of engaging vulnerable patients into these portals. The portal is a health technology tool that was developed with a mainstream, English-speaking audience in mind. Thus, there are valid concerns that such technologies will actually exacerbate health care disparities, conferring further advantages to the already advantaged. In this paper, we describe a framework for portal engagement (awareness, registration, and use) among safety net patients. We incorporate the experiences in the Los Angeles County Department of Health Services to illustrate important contextual factors for portal outreach in our safety net. Finally, we discuss considerations for moving forward with health technology in the safety net as the next version of patient portals are being developed.

Changes in Health Care-Related Financial Burden for US Families With Children Associated With the Affordable Care Act.

Importance: The Affordable Care Act (ACA) sought to improve access and affordability of health insurance. Although most ACA policies targeted childless adults, the extent to which these policies also impacted families with children remains unclear. Objective: To examine changes in health care-related financial burden for US families with children before and after the ACA was implemented based on income eligibility for ACA policies. Design, Setting, and Participants: Data used for this cohort study were obtained from the 2000-2017 Medical Expenditure Panel Survey, a nationally representative, population-based survey. Multivariable regression with a difference-in-differences estimator was used to examine changes in family financial burden before and after ACA implementation according to income-based ACA eligibility groups (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The cohort included 92 165 families with 1 or more children (age ≤18 years) and 1 or more adult parents/guardians. Exposures: Income-based eligibility groups during post-ACA years (calendar years 2014-2017) vs pre-ACA years (calendar years 2000-2013). Main Outcomes and Measures: Family annual out-of-pocket (OOP) health care and premium cost burden relative to income. High OOP burden was determined based on a previously validated algorithm with relative cost thresholds that vary across incomes, and extreme OOP burden was defined as costs exceeding 10% of income. Premiums exceeding 9.5% of income were classified as burdensome and premiums relative to median household income defined an unaffordability index. Results: Compared with high-income families who experienced a lesser change post-ACA implementation (high OOP burden, 1.1% pre-ACA vs 0.9% post-ACA), the lowest-income families saw the greatest reduction in high OOP burden (35.6% pre-ACA vs 23.7% post-ACA; difference-in-differences: -11.4%; 95% CI, -13.2% to -9.5%) followed by low-income families (24.6% pre-ACA vs 17.3% post-ACA, difference-in-differences: -6.8%; 95% CI, -8.7% to -4.9%) and middle-income families (6.1% pre-ACA vs 4.6% post-ACA, difference-in-differences: -1.2%; 95% CI, -2.3% to -0.01%). Although premiums rose for all groups, premium unaffordability was the least exacerbated for the lowest-, low-, and middle-income families compared with higher-income families. Conclusions and Relevance: The findings of this study suggest that low- and middle-income families with children who were eligible for ACA Medicaid expansions and Marketplace subsidies experienced greater reductions in health care-related financial burden after the ACA was implemented compared with families with higher incomes. However, despite ACA policies, many low- and middle-income families with children appear to continue to face considerable financial burden from premiums and OOP costs.

Did the Affordable Care Act Decrease Veteran Enrollment in the Veterans Health Administration?

BACKGROUND: Provisions of the Affordable Care Act (ACA) provided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends. METHODS: The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were compared between 3 enrollment groups: pre-2012, pre-ACA (2012-2013), and post-ACA (2014-2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics. RESULTS: A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups. CONCLUSIONS: The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care.

Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review.

BACKGROUND: Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE: To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN: We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS: Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS: Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.

The Affordable Care Act's Enduring Resilience.

The Affordable Care Act (ACA) has taken numerous blows, both from the courts and from opponents seeking to undermine it. Yet, due to its policy design and the political forces the ACA has unleashed, the law has shown remarkable resilience. While there remain ongoing efforts to undo the ACA, the smart money has to be on its continued existence.

The Health Resources and Services Administration's Ryan White HIV/AIDS Program in rural areas of the United States: Geographic distribution, provider characteristics, and clinical outcomes.

BACKGROUND: People living with HIV (PLWH) residing in rural areas experience substantial barriers to HIV care, which may contribute to poor HIV health outcomes, including retention in HIV care and viral suppression. The Health Resources and Services Administration's Ryan White HIV/AIDS Program (HRSA RWHAP) is an important source of HIV medical care and support services in rural areas. The purpose of this analysis was to (1) assess the reach of the RWHAP in rural areas of the United States, (2) compare the characteristics and funded services of RWHAP provider organizations in rural and non-rural areas, and (3) compare the characteristics and clinical outcomes of RWHAP clients accessing medical care and support services in rural and non-rural areas. METHODS AND FINDINGS: Data for this analysis were abstracted from the 2017 RWHAP Services Report (RSR), the primary source of annual, client-level RWHAP data. Organizations funded to deliver RWHAP any service ("RWHAP providers") were categorized as rural or non-rural according to the HRSA FORHP's definition of modified Rural-Urban Commuting Area (RUCA) codes. RWHAP clients were categorized based on their patterns of RWHAP service use as "visited only rural providers," "visited only non-rural providers," or "visited rural and non-rural providers." In 2017, among the 2,113 providers funded by the RWHAP, 6.2% (n = 132) were located in HRSA-designated rural areas. Rural providers were funded to deliver a greater number of service categories per site than non-rural providers (44.7% funded for ≥5 services vs. 34.1% funded for ≥5 services, respectively). Providers in rural areas served fewer clients than providers in non-rural areas; 47.3% of RWHAP providers in rural areas served 1-99 clients, while 29.6% of non-rural providers served 1-99 clients. Retention in care and viral suppression outcomes did not differ on the basis of whether a client accessed services from rural or non-rural providers. CONCLUSIONS: RWHAP providers are a crucial component of HIV care delivery in the rural United States despite evidence of significant barriers to engagement in care for rural PLWH, RWHAP clients who visited rural providers were just as likely to be retained in care and reach viral suppression as their counterparts who visited non-rural providers. The RWHAP, especially in partnership with Rural Health Clinics and federally funded Health Centers, has the infrastructure and expertise necessary to address the HIV epidemic in rural America.

Association of the Affordable Care Act Medicaid Expansion with Dilated Eye Examinations among the United States Population with Diabetes.

PURPOSE: To evaluate the association between Medicaid expansion and diabetic dilated eye examinations. DESIGN: A retrospective difference in differences (DiD) analysis using individual-level survey response data from January 1, 2009, to December 31, 2017. PARTICIPANTS: A total of 52 392 survey responses from 50 states and the District of Columbia between 2009 and 2017. Responders were adults aged 18 to 64 years reporting a previous diagnosis of diabetes and a household income below 138% of the US federal poverty line (FPL). METHODS: The Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System data were used to identify survey responders who were asked about the presence of dilated eye examinations from years before and after Medicaid expansion implementation. MAIN OUTCOME MEASURES: The DiD in proportion of dilated eye examinations among diabetic persons aged 18 to 64 years with household incomes below 138% of the FPL between states that did and did not implement Medicaid expansion. RESULTS: Implementation of Medicaid expansion policies was associated with a 1.3% (95% confidence interval [CI], -3.8 to 6.4; P = 0.61), 6.3% (95% CI, 1.3-11.3; P = 0.016), 4.1% (95% CI, -0.8 to 9.0; P = 0.11), and 2.3% (95% CI, -1.6 to 6.2; P = 0.23) increase in the proportion of diabetic persons aged 18 to 64 years with incomes below 138% of the FPL receiving a dilated eye examination within the past year due to Medicaid expansion 1, 2, 3, and 4 cumulative years after expansion, respectively. CONCLUSIONS: Medicaid expansion policies were significantly associated with an increase in dilated eye examination rates within the first 2 years after implementation. However, this increase did not persist beyond this period, with nonsignificant increases 3 and 4 cumulative years after implementation. Healthcare policymakers should be aware that additional measures beyond expanding insurance coverage may be necessary to increase and sustain the rate of dilated eye examinations among diabetic populations.

HHS Proposes Revisions to ACA Antidiscrimination Protections.

Transgender individuals and women who've terminated pregnancy would lose explicit protections under 'sex discrimination' umbrella.

Financial burden of cancer care under the Affordable Care Act: Analysis of MEPS-Experiences with Cancer Survivorship 2011 and 2016.

PURPOSE: To examine whether the implementation of Affordable Care Act (ACA) reduced the financial burden associated with cancer care among non-elderly cancer survivors. METHODS: Using data from the MEPS-Experiences with Cancer Survivorship Survey, we examined whether there was a difference in financial burden associated with cancer care between 2011 (pre-ACA) and 2016 (post-ACA). Two aspects of financial burden were considered: (1) self-reported financial burden, whether having financial difficulties associated with cancer care and (2) high-burden spending, whether total out-of-pocket (OOP) spending incurred in excess of 10% or 20% of family income. Generalized linear regression models were estimated to adjust the OOP expenditures (reported in 2016 US dollar). RESULTS: Our sample included adults aged 18-64 with a confirmed diagnosis of any cancer in 2011 (n = 655) and in 2016 (n = 490). There was no apparent difference in the prevalence of cancer survivors reporting any financial hardship or being with high-burden spending between 2011 and 2016. The mean OOP decreased by $268 (95% CI, - 384 to - 152) after the ACA. However, we found that the mean premium payments increased by $421 (95% CI, 149 to 692) in the same period. CONCLUSIONS: The ACA was associated with reduced OOP for health services but increased premium contributions, resulting in no significant impact on perceived financial burden among non-elderly cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: The financial hardship of cancer survivorship points to the need for the development of provisions that help cancer patients reduce both perceived and materialized burden of cancer care under ongoing health reform.

Posterior lumbar fusions at physician-owned hospitals - is it time to reconsider the restrictions of the Affordable Care Act?

BACKGROUND CONTEXT: Caused by perceptions regarding unnecessary healthcare resource utilization, high costs of care, and financial incentives towards "cherry-picking" cases in physician owned hospitals, the Affordable Care Act (ACA) of 2010 imposed restrictions on existing physician-owned hospitals from expanding. Despite an increasing number of individuals requiring access to spine surgical care, no study has evaluated the surgical safety and costs of elective posterior lumbar fusions (PLFs) being performed in physician-owned vs. non-physician-owned hospitals. PURPOSE: We assessed differences in 90-day costs and outcomes between patients undergoing elective 1- to 3-level PLFs at physician-owned hospitals vs. nonphysician-owned hospitals. STUDY DESIGN: Retrospective cohort study of 2007 to 2014 100% Medicare claims database. PATIENT SAMPLE: The 2007 to 2014 Medicare 100% Standard Analytical Files (SAF100) was queried using International Classification of Diseases 9th Edition (ICD-9) procedure code for patients undergoing elective 1- to 3-level PLFs (81.07, 81.08, and 81.62). The Medicare Hospital Compare database was used to identify provider codes for physician-owned hospitals. These provider codes were cross-referenced to identify records of patients receiving elective PLFs at these hospitals from the SAF100 database. OUTCOME MEASURES: Ninety day complications, readmissions, emergency department (ED) visits, charges, and costs. METHODS: Multivariate logistic and linear regression analyses were used to assess significant differences in 90-day complications, readmissions, charges and costs between the two groups. RESULTS: A total of 6,679 (2.9%) patients received an elective PLF at a physician-owned hospital (N=39; 2.2%) whereas 225,090 (97.1%) received surgery at nonphysician-owned hospital (N=1,774; 97.8%). After controlling for age, gender, region, hospital factors (socio-economic status area, urban vs. rural location and volume) and Elixhauser co-morbidity index, undergoing surgery at physician-owned hospital was associated with lower odds of thromboembolic complications (OR 0.66 [95% CI 0.53-0.82]; p<.001), urinary tract infections (OR 0.87 [95% CI 0.79-0.95]; p=.002) and renal complications (OR 0.52 [95% CI 0.43-0.63]; p<.001) within 90-days following the surgery. Patients undergoing PLFs at physician-owned hospitals vs. nonphysician-owned hospitals also had lower risk-adjusted inpatient charges (-$10,218), inpatient costs (-$2,302), 90-day charges (-$9,780) and 90-day costs (-$2,324). No significant differences were noted between physician-owned and nonphysician-owned hospitals with regards to 90-day wound complications (OR 1.08 [95% CI 0.94-1.22]; p=.279), pulmonary complications (OR 1.06 [95% CI 0.97-1.17]; p=.187), cardiac complications (OR 0.92 [95% CI 0.83-1.01]; p=.089), septic complications (OR 0.77 [95% CI 0.56-1.01]; p=.073), all-cause ED visits (OR 0.96 [95% CI 0.89-1.04]; p=.311), revision surgery (OR 1.09 [95% CI 0.72-1.59]; p=.653) and readmissions (OR 0.98 [95% CI 0.89-1.08]; p=.680). CONCLUSION: Our results suggest that patients undergoing elective 1- to 3-level PLFs at physician-owned hospitals do not experience a greater number of complications and/or readmissions while having lower risk-adjusted charges and costs over the 90-day episode of care. The findings call on the need for revaluation/reconsideration of the ACAs restriction on the expansion of these physician-owned hospitals.

Litigation Continues; Payment Rule Arrives.

Spring brings legal challenges for the administration agenda, the latest payment rule ever, more twists in Texas, and new action in Congress.

["ObamaCare": effects for the health reform in Chile]. / Repercusiones de "ObamaCare" para la reforma sanitaria en Chile.

Health care raises structural issues in a democratic society, such as the role assigned to the central government in the management of health risk and the redistributive consequences generated by the implementation of social insurance. These are often cause of strong political controversy. This paper examines the United States of America health reform, popularly known as "ObamaCare". Its three main elements, namely individual mandate, creation of new health insurance exchanges, and the expansion of Medicaid, generated a redistribution of health risks in the insurance market of that country after almost a century of frustrated legislative efforts to guarantee minimum universal coverage. The article proposes that a change of this magnitude in the United States will produce effects in a forthcoming parliamentary discussion on the health reform in Chile, which still maintains a highly deregulated private health system.

How Patients' Stories Shape Their Votes: The Role of Health Care in the 2018 U.S. Midterm Elections.

Reflecting on the 2018 U.S. midterm elections, it is clear that health care coverage once again played an important role. This prompted the authors to look back on their 2016 bike listening tour across the country when they asked people about their views on the Affordable Care Act. Through those conversations, the authors observed that a common thread was the rampant misunderstanding of health insurance coverage and the central role that politicians had in the creation of policy. In this Invited Commentary, the authors explore the results of the 2018 election, particularly in the rural northern areas where they toured in 2016, and the contradictions between what people say they want, what the candidates say they support, and what the facts actually show. They offer suggestions for the role physicians might play with patients in correcting misunderstandings about the health care system and the policies that shape it. Patients do not always make decisions as physicians do. As opposed to evidence and data, they might rely on personal experiences and stories. The authors suggest that physicians might be able to help patients use these stories to inform their decisions, and to help them understand the connection between their personal health care experiences and the votes they cast in elections.

Repercusiones de "ObamaCare" para la reforma sanitaria en Chile / "ObamaCare": effects for the health reform in Chile

Health care raises structural issues in a democratic society, such as the role assigned to the central government in the management of health risk and the redistributive consequences generated by the implementation of social insurance. These are often cause of strong political controversy. This paper examines the United States of America health reform, popularly known as "ObamaCare". Its three main elements, namely individual mandate, creation of new health insurance exchanges, and the expansion of Medicaid, generated a redistribution of health risks in the insurance market of that country after almost a century of frustrated legislative efforts to guarantee minimum universal coverage. The article proposes that a change of this magnitude in the United States will produce effects in a forthcoming parliamentary discussion on the health reform in Chile, which still maintains a highly deregulated private health system.

Mining Open Payments Data: Analysis of Industry Payments to Thoracic Surgeons From 2014-2016.

BACKGROUND: The financial relationship between physicians and industries has become a hotly debated issue globally. The Physician Payments Sunshine Act of the US Affordable Care Act (2010) promoted transparency of the transactions between industries and physicians by making remuneration data publicly accessible in the Open Payments Program database. Meanwhile, according to the World Health Organization, the majority of all noncommunicable disease deaths were caused by cardiovascular disease. OBJECTIVE: This study aimed to investigate the distribution of non-research and non-ownership payments made to thoracic surgeons, to explore the regularity of financial relationships between industries and thoracic surgeons. METHODS: Annual statistical data were obtained from the Open Payments Program general payment dataset from 2014-2016. We characterized the distribution of annual payments with single payment transactions greater than US $10,000, quantified the major expense categories (eg, Compensation, Consulting Fees, Travel and Lodging), and identified the 30 highest-paying industries. Moreover, we drew out the financial relations between industries to thoracic surgeons using chord diagram visualization. RESULTS: The three highest categories with single payments greater than US $10,000 were Royalty or License, Compensation, and Consulting Fees. Payments related to Royalty or License transferred from only 5.38% of industries to 0.75% of surgeons with the highest median (US $13,753, $11,992, and $10,614 respectively) in 3-year period. In contrast, payments related to Food and Beverage transferred from 93.50% of industries to 98.48% of surgeons with the lowest median (US $28, $27, and $27). The top 30 highest-paying industries made up approximately 90% of the total payments (US $21,036,972, $23,304,996, and $28,116,336). Furthermore, just under 9% of surgeons received approximately 80% of the total payments in each of the 3 years. Specifically, the 100 highest cumulative payments, accounting for 52.69% of the total, transferred from 27 (6.05%) pharmaceutical industries to 86 (1.89%) thoracic surgeons from 2014-2016; 7 surgeons received payments greater than US $1,000,000; 12 surgeons received payments greater than US $400,000. The majority (90%) of these surgeons received tremendous value from only one industry. CONCLUSIONS: There exists a great discrepancy in the distribution of payments by categories. Royalty or License Fees, Compensation, and Consulting Fees are the primary transferring channels of single large payments. The massive transfer from industries to surgeons has a strong "apical dominance" and excludability. Further research should focus on discovering the fundamental driving factors for the strong concentration of certain medical devices and how these payments will affect the industry itself.

Television Advertising and Health Insurance Marketplace Consumer Engagement in Kentucky: A Natural Experiment.

BACKGROUND: Reductions in health insurance enrollment outreach could have negative effects on the individual health insurance market. Specifically, consumers may not be informed about the availability of coverage, and if some healthier consumers fail to enroll, there could be a worse risk pool for insurers. Kentucky created its own Marketplace, known as kynect, and adopted Medicaid expansion under the Affordable Care Act, which yielded the largest decline in adult uninsured rate in the United States from 2013 to 2016. The state sponsored an award-winning media campaign, yet after the election of a new governor in 2015, it declined to renew the television advertising contract for kynect and canceled all pending television ads with over a month remaining in the 2016 open enrollment period. OBJECTIVE: The objective of this study is to examine the stark variation in television advertising across multiple open enrollment periods in Kentucky and use this variation to estimate the dose-response effect of state-sponsored television advertising on consumer engagement with the Marketplace. In addition, we assess to what extent private insurers can potentially help fill the void when governments reduce or eliminate television advertising. METHODS: We obtained television advertising (Kantar Media/Campaign Media Analysis Group) and Marketplace data (Kentucky Health Benefit Exchange) for the period of October 1, 2013, through January 31, 2016, for Kentucky. Advertising data at the spot level were collapsed to state-week counts by sponsor type. Similarly, a state-week series of Marketplace engagement and enrollment measures were derived from state reports to Centers for Medicare and Medicaid Services. We used linear regression models to estimate associations between health insurance television advertising volume and measures of information-seeking (calls to call center; page views, visits, and unique visitors to the website) and enrollment (Web-based and total applications, Marketplace enrollment). RESULTS: We found significant dose-response effects of weekly state-sponsored television advertising volume during open enrollment on information-seeking behavior (marginal effects of an additional ad airing per week for website page views: 7973, visits: 390, and unique visitors: 388) and enrollment activity (applications, Web-based: 61 and total: 56). CONCLUSIONS: State-sponsored television advertising was associated with nearly 40% of unique visitors and Web-based applications. Insurance company television advertising was not a significant driver of engagement, an important consideration if cuts to government-sponsored advertising persist.

Behavioral Health Coverage In The Individual Market Increased After ACA Parity Requirements.

As of January 1, 2014, the Affordable Care Act designated mental health and substance use services as an essential health benefit in Marketplace plans and extended parity protections to the individual and small-group markets. We analyzed documents for seventy-eight individual and small-group plans in 2014 (after parity provisions took effect) and sixty comparison plans in 2013 (the year before parity provisions took effect) to understand the degree to which coverage for mental health and substance use care improved relative to medical/surgical benefits. The results suggest that plan issuers did what the provisions required them to do. Although in 2013 a lower proportion of plans covered mental health or substance use care, compared to medical/surgical care, in 2014 the proportions were the same. If essential health benefit requirements were to be removed and mental health and substance use coverage becomes similar to that in 2013, as many as 20 percent of the plans in our sample would not cover these conditions. To determine whether increases in behavioral health coverage will result in improved access to behavioral health services requires complementary data on the size of provider networks and use of services.