Examining Measures of Income and Poverty in Medicare Administrative Data.

Disparities by economic status are observed in the health status and health outcomes of Medicare beneficiaries. For health services and health policy researchers, one barrier to addressing these disparities is the ability to use Medicare data to ascertain information about an individual's income level or poverty, because Medicare administrative data contains limited information about individual economic status. Information gleaned from other sources-such as the Medicaid and Supplemental Security Income programs-can be used in some cases to approximate the income of Medicare beneficiaries. However, such information is limited in its availability and applicability to all beneficiaries. Neighborhood-level measures of income can be used to infer individual-level income, but level of neighborhood aggregation impacts accuracy and usability of the data. Community-level composite measures of economic status have been shown to be associated with health and health outcomes of Medicare beneficiaries and may capture neighborhood effects that are separate from individual effects, but are not readily available in Medicare data and do not serve to replace information about individual economic status. There is no single best method of obtaining income data from Medicare files, but understanding strengths and limitations of different approaches to identifying economic status will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using measures of income.

Insurance coverage of emergency care for young adults under health reform.

BACKGROUND: The Affordable Care Act (ACA) established nationwide eligibility for young adults 19 to 25 years of age to retain coverage under their parents' private health plans. We conducted a study to determine how the implementation of this provision changed rates of insurance coverage for young adults seeking medical care for major emergencies. METHODS: We evaluated more than 480,000 nondiscretionary visits made to emergency departments from 2009 through 2011, as recorded in a large, geographically diverse data set of hospital claims, to estimate how the ACA provision affected private insurance coverage of such visits by young adults (19 to 25 years of age). To adjust for underlying trends in insurance coverage, we compared changes in the target age group with changes among adults 26 to 31 years of age, who were unaffected by the provision (control group). RESULTS: After the ACA provision took effect, private coverage of nondiscretionary visits to emergency departments by young adults increased by 3.1 percentage points (95% confidence interval [CI], 2.3 to 3.9; relative increase, 5.2%; P<0.001), as compared with similar visits in the control group. The percentage of visits by uninsured young adults also fell significantly (-1.7 percentage points; 95% CI, -2.8 to -0.7; relative decrease, 9.1%; P<0.001). The rates of nondiscretionary visits that were covered by Medicaid or other nonprivate insurers remained relatively steady throughout the study period. The coverage expansion led to an estimated 22,072 visits to emergency departments by newly insured young adults and $147 million in associated costs that were covered by private insurance plans during a 1-year period. CONCLUSIONS: Enactment of the dependent-coverage provision was associated with a significant increase in the proportion of young adults who were protected from the financial consequences of a serious medical emergency. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.).

Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act.

IMPORTANCE: The Affordable Care Act (ACA) completed its second open enrollment period in February 2015. Assessing the law's effects has major policy implications. OBJECTIVES: To estimate national changes in self-reported coverage, access to care, and health during the ACA's first 2 open enrollment periods and to assess differences between low-income adults in states that expanded Medicaid and in states that did not expand Medicaid. DESIGN, SETTING, AND PARTICIPANTS: Analysis of the 2012-2015 Gallup-Healthways Well-Being Index, a daily national telephone survey. Using multivariable regression to adjust for pre-ACA trends and sociodemographics, we examined changes in outcomes for the nonelderly US adult population aged 18 through 64 years (n = 507,055) since the first open enrollment period began in October 2013. Linear regressions were used to model each outcome as a function of a linear monthly time trend and quarterly indicators. Then, pre-ACA (January 2012-September 2013) and post-ACA (January 2014-March 2015) changes for adults with incomes below 138% of the poverty level in Medicaid expansion states (n = 48,905 among 28 states and Washington, DC) vs nonexpansion states (n = 37,283 among 22 states) were compared using a differences-in-differences approach. EXPOSURES: Beginning of the ACA's first open enrollment period (October 2013). MAIN OUTCOMES AND MEASURES: Self-reported rates of being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, overall health status, and health-related activity limitations. RESULTS: Among the 507,055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes. Compared with the pre-ACA trends, by the first quarter of 2015, the adjusted proportions who were uninsured decreased by 7.9 percentage points (95% CI, -9.1 to -6.7); who lacked a personal physician, -3.5 percentage points (95% CI, -4.8 to -2.2); who lacked easy access to medicine, -2.4 percentage points (95% CI, -3.3 to -1.5); who were unable to afford care, -5.5 percentage points (95% CI, -6.7 to -4.2); who reported fair/poor health, -3.4 percentage points (95% CI, -4.6 to -2.2); and the percentage of days with activities limited by health, -1.7 percentage points (95% CI, -2.4 to -0.9). Coverage changes were largest among minorities; for example, the decrease in the uninsured rate was larger among Latino adults (-11.9 percentage points [95% CI, -15.3 to -8.5]) than white adults (-6.1 percentage points [95% CI, -7.3 to -4.8]). Medicaid expansion was associated with significant reductions among low-income adults in the uninsured rate (differences-in-differences estimate, -5.2 percentage points [95% CI, -7.9 to -2.6]), lacking a personal physician (-1.8 percentage points [95% CI, -3.4 to -0.3]), and difficulty accessing medicine (-2.2 percentage points [95% CI, -3.8 to -0.7]). CONCLUSIONS AND RELEVANCE: The ACA's first 2 open enrollment periods were associated with significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health. Low-income adults in states that expanded Medicaid reported significant gains in insurance coverage and access compared with adults in states that did not expand Medicaid.

Projected US savings from biosimilars, 2021-2025.

OBJECTIVES: Biologics account for an increasing share of US prescription drug spending. Biosimilars could lower biologic prices through competition, but barriers to increasing both supply and uptake remain. We projected US biosimilar savings from 2021 to 2025 under different scenarios. STUDY DESIGN: We projected US spending on biologics over a 5-year period under 3 scenarios: (1) a baseline scenario holding quarter 4 (Q4) of 2020 market conditions constant; (2) under main assumptions allowing for biosimilar market growth and entry; and (3) an upper-bound scenario assuming greater biosimilar uptake, more robust price competition, and quicker biosimilar entry. METHODS: We first analyzed 2014-2020 US volume and price data from IQVIA's MIDAS database for biologics already facing biosimilar competition to inform model parameter values. We used these inputs to project biosimilar entry, biosimilar volume shares, biosimilar prices, and reference biologic prices. We calculated 2021-2025 new savings from biosimilar competition vs the Q4 2020 baseline. RESULTS: Estimated biosimilar savings from 2021 to 2025 under our main approach were $38.4 billion, or 5.9% of projected spending on biologics over the same period. Biologics first facing biosimilar competition from 2021 to 2025 accounted for $26.1 billion of savings, with $12.2 billion from evolving market conditions for already-marketed biosimilars. Furthermore, $24.6 billion of savings under our main approach were from downward pressure on reference biologic prices rather than lower biosimilar prices. Savings were substantially higher ($124.5 billion) under the upper-bound scenario. CONCLUSIONS: Biosimilar savings from 2021 to 2025 were $38.4 billion under our main assumptions. Greater savings may be feasible if managed care and other settings increase biosimilar utilization and promote competition.

COVID-19-Related Deaths And Excess Deaths Among Medicare Fee-For-Service Beneficiaries.

Millions of Americans have been infected with SARS-CoV-2, and more than 575,000 had died as of early May 2021. Understanding who are the most vulnerable populations for COVID-19 mortality and excess deaths is critical, especially as the US prioritizes vaccine distribution. Using Medicare administrative data, we found that beneficiaries residing in nursing homes, the oldest beneficiaries, members of racial/ethnic minority groups, beneficiaries with multiple comorbid conditions, and beneficiaries who are dually eligible for Medicare and Medicaid were disproportionately likely to die after infection with SARS-CoV-2. As the pandemic developed, Medicare data were quickly adapted to provide analyses and inform the nation's response to COVID-19. Similar data for the rest of the population, however, are not readily available. Developing policies and methods around data collection and access will be important to address the consequences of future pandemics and other health emergencies.

Associations Between the Patient Protection and Affordable Care Act Medicaid Primary Care Payment Increase and Physician Participation in Medicaid.

Importance: The Patient Protection and Affordable Care Act (ACA) increased 2013 to 2014 Medicaid payment rates for qualifying primary care physicians (PCPs) and services to higher Medicare payment levels, with the goal of improving primary care access for Medicaid enrollees. Objectives: To evaluate the payment increase policy and to assess whether it was associated with changes in Medicaid participation rates or Medicaid service volume among PCPs. Design, Setting, and Participants: This study used 2012 to 2015 IMS Health aggregated medical claims and encounter data from PCPs eligible for the payment increase practicing in all states except Alaska and Hawaii and included 20 723 PCPs with observations in each month from January 1, 2012, to December 31, 2015. Data are for professional services performed in ambulatory settings, including office, hospital outpatient department, and emergency department. Regression models were used to test whether outcomes differed in months subject to higher payment rates relative to months before the increase and after the expiration of the increase in some states. The models controlled for time-invariant physician characteristics and time-varying characteristics, such as Medicaid enrollment. Interaction terms were included to estimate differential associations in subgroups of states (eg, by Medicaid managed care penetration) and physicians (eg, by specialty). Main Outcomes and Measures: Physician-month records subject to higher Medicaid payment rates were flagged using state-specific implementation and end dates for the payment increase. Five outcomes were measured for each physician-month observation, including (1) an indicator for seeing any patients enrolled in Medicaid, (2) an indicator for seeing more than 5 patients enrolled in Medicaid, (3) the Medicaid share of total patients, (4) a count of new patient evaluation and management visits furnished to patients enrolled in Medicaid, and (5) a count of existing patient evaluation and management visits furnished to patients enrolled in Medicaid. Results: Among 20 723 PCPs, the payment increase had no association with PCP participation in Medicaid or Medicaid service volume. The estimated average marginal effects for all 5 outcomes were not statistically distinguishable from 0. This null result was robust to sensitivity analyses, including different time trend specifications and analyses focusing on the payment increase implementation and expiration time frames. Descriptively, the Medicaid share of patients increased by about 25% from 2012 to 2015, although the share did not increase differentially in states and months subject to higher payment rates. Conclusions and Relevance: The limited duration and design of the payment increase may have dampened its effectiveness. Future efforts to improve access through payment changes or other means can benefit from better understanding of the outcomes of this policy.

Do individuals respond to cost-sharing subsidies in their selections of marketplace health insurance plans?

The Affordable Care Act (ACA) provides assistance to low-income consumers through both premium subsidies and cost-sharing reductions (CSRs). Low-income consumers' lack of health insurance literacy or information regarding CSRs may lead them to not take-up CSR benefits for which they are eligible. We use administrative data from 2014 to 2016 on roughly 22 million health insurance plan choices of low-income individuals enrolled in ACA Marketplace coverage to assess whether they behave in a manner consistent with being aware of the availability of CSRs. We take advantage of discontinuous changes in the schedule of CSR benefits to show that consumers are highly sensitive to the value of CSRs when selecting insurance plans and that a very low percentage select dominated plans. These findings suggest that CSR subsidies are salient to consumers and that the program is well designed to account for any lack of health insurance literacy among the low-income population it serves.

Gaining Coverage Through Medicaid Or Private Insurance Increased Prescription Use And Lowered Out-Of-Pocket Spending.

A growing body of literature describes how the Affordable Care Act (ACA) has expanded health insurance coverage. What is less well known is how these coverage gains have affected populations that are at risk for high health spending. To investigate this issue, we used prescription transaction data for a panel of 6.7 million prescription drug users to compare changes in coverage, prescription fills, plan spending, and out-of-pocket spending before and after the implementation of the ACA's coverage expansion. We found a 30 percent reduction in the proportion of this population that was uninsured in 2014 compared to 2013. Uninsured people who gained private coverage filled, on average, 28 percent more prescriptions and had 29 percent less out-of-pocket spending per prescription in 2014 compared to 2013. Those who gained Medicaid coverage had larger increases in fill rates (79 percent) and reductions in out-of-pocket spending per prescription (58 percent). People who gained coverage who had at least one of the chronic conditions detailed in our study saw larger decreases in out-of-pocket spending compared to those who did not have at least one condition. These results demonstrate that by reducing financial barriers to care, the ACA has increased treatment rates while reducing out-of-pocket spending, particularly for people with chronic conditions.

Changes in health insurance coverage and health status by race and ethnicity, 1997-2002.

Recent years have seen shifts in health insurance coverage associated with economic fluctuations and changes in health policy. The analysis presented here uses data from the National Survey of America's Families to examine changes in health insurance coverage and respondent-reported health status by race and ethnicity. The data indicate that public coverage increased for black, Hispanic and white children between 1997 and 2002. Uninsurance rates fell among children in low-income black, Hispanic and white families, remained constant among black and white children in higher-income families, and increased among higher-income Hispanic children. The health status of children was stable for blacks, Hispanics and whites except for a decline in health among higher-income Hispanic children. Black and white adults saw increases in public health insurance coverage but not in overall coverage. The uninsurance rate of Hispanic adults increased, despite expanded public coverage of higher-income Hispanic adults. None of these developments altered racial and ethnic disparities in health. Hispanics fared worse than blacks in both health status and insurance coverage, and blacks fared worse than whites. Given the anticipated growth of minority populations in the United States, the nation's health will deteriorate if policymakers allow current disparities to continue.

Seven million Americans live in areas where demand for primary care may exceed supply by more than 10 percent.

The Affordable Care Act's expansion of insurance coverage is expected to increase demand for primary care services. We estimate that the national increase in demand for such services will require 7,200 additional primary care providers, or 2.5 percent of the current supply. On average, that increased demand is unlikely to prove disruptive. But when we examined how this increased demand will be experienced in different areas of the country, we found considerable variability: Seven million people live in areas where the expected increase in demand for providers is greater than 10 percent of baseline supply, and forty-four million people live in areas with an expected increase in demand above 5 percent of baseline supply. These findings highlight the need to promote policies that encourage more primary care providers and community health centers to practice in areas with the greatest expected need for services.