Georgia's Reinsurance Waiver Associated With Decreased Premium Affordability And Enrollment.

Sixteen states have used Section 1332 waivers to implement reinsurance programs that aim to reduce premiums and increase enrollment in the Affordable Care Act's health insurance Marketplaces. Although reinsurance programs have successfully reduced premiums for unsubsidized enrollees, little is known about how reinsurance affects Marketplace premiums, minimum cost of coverage, and enrollment for the large majority of Marketplace enrollees who receive premium subsidies. Using a difference-in-differences analysis of matched counties straddling Georgia's borders to examine Georgia's 2022 implementation of its reinsurance program, we found that reinsurance increased the minimum cost of enrolling in subsidized Marketplace coverage by approximately 30 percent and decreased enrollment by roughly a third for Marketplace enrollees with incomes of 251-400 percent of the federal poverty level. Marketplace reinsurance programs may have the unintended consequences of increasing the minimum cost of subsidized coverage and reducing enrollment. These outcomes are especially relevant in the present policy context of enhanced subsidies, which have substantially reduced the number of unsubsidized enrollees who would benefit most from reinsurance.

Episode-Based Cost Sharing to Prospectively Guarantee Patients' Out-of-Pocket Costs.

This Viewpoint proposes episode-based cost sharing as a way to prospectively guarantee out-of-pocket costs for patients while also preventing insurers from absorbing cost differentials created by unexpected complications of care.

Investing in Child Health Through Alternative Payment Models: Lessons From North Carolina Integrated Care for Kids.

Pediatric value-based payment reform has been hindered by limited return on investment (ROI) for child-focused measures and the accrual of financial benefits to non-health care sectors. States participating in the federally-funded Integrated Care for Kids (InCK) models are required to design child-centered alternative payment models (APMs) for Medicaid-enrolled children. The North Carolina InCK pediatric APM launched in January 2023 and includes innovative measures focused on school readiness and social needs. We interviewed experts at NC Medicaid managed care organizations, NC Medicaid, and actuaries with pediatric value-based payment experience to assess the NC InCK APM design process and develop strategies for future child-focused value-based payment reform. Key principles emerging from conversations included: accounting for payer priorities and readiness to implement measures; impact of data uncertainty on investment in novel measures; misalignment of a short-term ROI framework with whole child health measures; and state levers like mandates and financial incentives to promote implementation.

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization.

Importance: Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults. Objective: To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year. Design, Setting, and Participants: This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021. Main Outcomes and Measures: Primary outcomes were total cost of care and care utilization during the 2018 performance year. Results: Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care. Conclusions and Relevance: This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

Dynamic Price Competition for Low-Cost Silver Plans on Healthcare.gov 2014-2021.

More than 16 million people receive health care coverage through the Affordable Care Act's (ACA) individual health insurance marketplaces. Many enrollees receive premium subsidies that are tied to the premium of the second least expensive silver plan available. This study investigates the consistency of the least expensive silver plan offered on Healthcare.gov from 2014 to 2021 and finds that on average, from one year to the next, the same insurer offered the least expensive silver plan in 63.1% of counties representing 54.7% of the population. However, even when the same insurer offers the least expensive plan, almost half the time, they introduce a new, less expensive plan in the next policy year. Consequently, ACA enrollees who previously purchased the least expensive silver plan may face incremental premium costs unless they spend time and effort to carefully reevaluate their choices each year. We estimate the potential premium cost of inattention and show how it varies over time and across states.

Patient Cost Exposure And Use Of Preventive Care Among ACA-Compliant Individual Plans.

The Affordable Care Act (ACA) mandated coverage of common preventive services with zero patient cost sharing. However, patients may still experience high same-day costs when receiving these "zero-dollar" preventive services. Our analysis of on- and off-exchange individual-market health plans during 2016-18 revealed that 21-61 percent of enrollees experienced same-day cost exposure greater than $0 when accessing ACA-mandated free preventive services.

Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019.

Importance: The Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear. Objectives: To describe individual marketplace enrollees' metal tier selections by risk score and assess enrollees' health spending by metal tier, risk score, and spending type. Design, Setting, and Participants: This retrospective, cross-sectional study analyzed claims data from the Wakely Consulting Group ACA database, a deidentified claims database built on data voluntarily submitted by insurers. Enrollees with continuous, full-year enrollment in on-exchange or off-exchange ACA-qualified health plans during the 2019 contract year were included. Data analysis was conducted from March 2021 to January 2023. Main Outcomes and Measures: Enrollment totals, total spending, and out-of-pocket cost were calculated, stratified by metal tier and the Department of Health and Human Services (HHS) Hierarchical Condition Category (HCC) risk score for 2019. Results: Enrollment and claims data were obtained for 1 317 707 enrollees (53.5% female; mean [SD] age, 46.35 [13.43] years) across all census areas, age groups, and sexes. Of these, 34.6% were on plans with cost-sharing reductions (CSRs), 75.5% did not have an assigned HCC, and 84.0% submitted at least 1 claim. Compared with enrollees in bronze plans (17.2%), enrollees were more likely to be classified in the top HHS-HCC risk quartile if they selected platinum (42.0%), gold (34.4%), or silver (29.7%) plans. The highest share of enrollees with $0 total spending was noted with the catastrophic (26.4%) and bronze (22.7%) plans, while gold plans had the lowest share (8.1%). Median total spending was lower among bronze plan enrollees ($593; IQR, $28-$2100) vs platinum ($4111; IQR, $992-$15 821) or gold ($2675; IQR, $728-$9070). Within the top risk score decile, CSR enrollees had less average total spending than any other metal tier by more than 10%. Conclusions and Relevance: In this cross-sectional study of the ACA individual marketplace, enrollees who selected plans with higher actuarial value also had greater mean HHS-HCC risk scores and health spending. The findings suggest these differences may be associated with variation in benefit generosity by metal tier, enrollee's perceptions of future health needs, or other barriers to care access.

Association of Funding Cuts to the Patient Protection and Affordable Care Act Navigator Program With Privately Sponsored Television Advertising.

Importance: Many individuals eligible for coverage in the Patient Protection and Affordable Care Act (ACA) marketplace remain unenrolled because of information barriers. Whether the private sector or the public sector should conduct outreach to address these barriers is a topic of active debate. Objective: To determine whether cuts to the funding of the ACA navigator program were associated with changes in the volume of private sector advertising. Design, Setting, and Participants: Using data from the 2015 to 2019 open enrollment periods, this economic evaluation analyzed the changes in advertising associated with 2017 to 2019 cuts to navigator program funding. A difference-in-difference analysis was used to compare outcomes before and after the cuts in counties with higher and lower exposure to the navigator program. Health insurance advertising was measured using data from Kantar/Campaign Media Analysis Group in collaboration with the Wesleyan Media Project, the most comprehensive data available on local broadcast and national cable advertising. The data set included all counties that met the eligibility criteria for the navigator program from 2015 through 2019. Data were analyzed from August 2021 to May 2022. Exposures: Counties were classified as having higher or lower exposure to the navigator program according to the intensity of program activity in 2016, before the funding cuts. Counties served only by statewide navigator programs were categorized as lower exposure, while those also served by local navigator programs were categorized as higher exposure. Main Outcomes and Measures: Number of privately sponsored television advertisement airings for the ACA individual health insurance marketplace during the 2015 to 2019 open enrollment periods in each county, adjusted for population. Results: All counties in 33 states that met the eligibility criteria for the navigator program from 2015 through 2019 were included in the analysis (2435 counties). Cuts to the navigator program were not associated with changes in the number of privately sponsored health insurance advertisements aired. Results were similar under several alternative approaches including an event study specification. Conclusions and Relevance: In this study of the association between television advertising and navigator funding in the ACA marketplaces, private sector entities did not increase their advertising to compensate for declines in government-sponsored navigator activity. This finding can inform policy debates about the extent to which the private sector adjusts in response to changes in government outreach, and thus improve the design of state waivers and federal funding allocations.

Trends in Location of Death Among Older Adult Americans After Falls.

Introduction: Fall-related mortality is increasing among older adults, yet trends and changes in the location of fall-attributed deaths are unknown; additionally, potential disparities are understudied. Methods: To assess trends/factors associated with place of death among older adult fall deaths in the US, a cross-sectional analysis of deaths using mortality data from 2003-2017 was performed. Results: Most deaths occurred in hospitals, however, the proportion decreased from 66.4% (n = 9,095) to 50.7% (n = 15,817). The proportion occurring in nursing facilities decreased from 15.9% (n = 2175) to 15.3% (n = 4,778), while deaths at home and in hospice facilities increased. Male, Black, Native American, and married decedents had increased odds of hospital death. Conclusion: As fall deaths increase among older adults, end-of-life needs of this population deserve increased attention. Research should explore needs and preferences of older adults who experience falls and their caregivers to reduce disparities in place of death and to ensure high quality of care is received.

Increasing Insurance Choices In The Affordable Care Act Marketplaces, 2018-21.

The Affordable Care Act (ACA) relies on insurers to offer health plans in the individual health insurance Marketplaces. Since the ACA's implementation, levels of Marketplace competition have varied, reaching a nadir in 2018. We examined the characteristics of counties that experienced changes in insurers' participation in the ACA Marketplaces from 2016 to 2021. Using data from the Kaiser Family Foundation and other sources, we found that 1,968 counties (accounting for 66 percent of the US population younger than age sixty-five) have more insurers in 2021 than in 2018, whereas only twelve counties (comprising 0.4 percent of the US nonelderly population) have fewer insurers. The number of counties with monopolist Marketplace insurers declined from 1,616 in 2018 to 294 in 2021. Recent Marketplace insurer gains were more likely in counties that lost insurers from 2016 to 2018 or had a monopolist insurer in 2018. Increased competition may lead to lower gross premiums in the ACA Marketplaces. Given the Biden administration's support for the ACA Marketplaces, it appears likely that the ACA individual health insurance market will be stable and profitable for the next several years.

Association Of Unemployment With Medicaid Enrollment By Social Vulnerability In North Carolina During COVID-19.

The COVID-19 pandemic precipitated an unemployment crisis in the US that surpassed the Great Recession of 2007-09 within the first three months of the pandemic. This article builds on the limited early evidence of the relationship between the pandemic and health insurance coverage, using county-level unemployment and Medicaid enrollment data from North Carolina, a large state that did not expand Medicaid. We used linear and county fixed effects models to assess this relationship, accounting for county-level social vulnerability, physical and virtual access to Medicaid enrollment, and COVID-19 case burden. Using data from January 2018 through August 2020, we estimated that the passthrough rate-the share of unemployed people who gained Medicaid coverage-was approximately 15 percent statewide but higher in more socially vulnerable counties. This low passthrough rate during a period of increased unemployment resulting from the COVID-19 pandemic means that Medicaid was unable to completely fulfill its countercyclical role, in which it grows to meet greater need during periods of widespread economic hardship, because of North Carolina's stringent Medicaid eligibility criteria. Working toward greater adoption of Medicaid expansion may help ensure that the US is better prepared for the next crisis by ensuring access to health insurance coverage.

Changes in Marketplace competition and television advertising by insurers.

OBJECTIVES: The Trump administration ended television advertising for the Health Insurance Marketplace prior to the 2018 open enrollment period, leaving insurers as the predominant source of health insurance advertising. Prior research findings are mixed on the effectiveness of private advertising on Marketplace enrollment, but no work to date has examined how competitive changes in health insurance markets are related to marketing patterns. This study provides the first evidence on how insurers are altering their marketing in response to changes in competition. STUDY DESIGN: This study links data capturing Marketplace participation (CMS Qualified Health Plan Landscape files) by county and health insurance advertising (Kantar Media/Campaign Media Analysis Group) by media market for the 2014 through 2018 open enrollment periods. METHODS: We used population-weighted county fixed effects models to estimate the relationship between year-over-year changes in Marketplace competition and changes in (1) total private advertising and (2) advertising per insurer. RESULTS: Going from multiple insurers to a single insurer resulted in 465 fewer private ads aired within a county during open enrollment (P < .01), a 17% to 38% reduction. Losing monopoly status is associated with a drop in advertising of 452 airings per insurer (P < .01), and becoming a monopolist is associated with 293 more airings per insurer (P < .01). CONCLUSIONS: Insurers are not replacing the decline in government-sponsored advertising. We find that insurers behave as if they are responding to strategic incentives, advertising more when they become a monopolist but not filling the hole left by their former competitor, which has implications for the volume of messages seen by consumers.

Estimated Plan Enrollment Outcomes After Changes to US Health Insurance Marketplace Automatic Renewal Rules.

Importance: The American Rescue Plan increases premium subsidies for health insurance marketplace enrollees, potentially leading to situations in which enrollees could switch to other health care plans with lower premiums and less cost sharing (ie, deductibles and copayments). Current policy defaults enrollees to their current health care plan if they automatically renew their coverage, which may cause them to stay in health care plans that, because of the American Rescue Plan, are now dominated in that they have higher premiums and cost sharing than other options. Objective: To estimate the extent to which a smart default policy could reduce US health insurance marketplace enrollees' cost sharing and premiums. Design Setting and Participants: Using 2018 individual enrollment data and 2021 premium data from California's marketplace and the American Rescue Plan premium tax credit subsidy schedule, this economic analysis estimated the characteristics of enrollees' default health care plans if they defaulted into 2021 health care plans under current and smart default policies. The analysis was conducted from March 20 to April 8, 2021. Main Outcomes and Measures: Characteristics of enrollees' default health care plans under current and smart default policies, including net premiums, plan levels, and cost sharing. Results: The analytic sample consisted of 748 087 Covered California enrollees from 2018 (mean [SD] age, 44.80 [13.72] years; 408 410 [54.6%] women). Under current policy with the enhanced subsidies implemented under the American Rescue Plan, 5.8% of sample enrollees would default into dominated health plans. Of these enrollees, 98.0% would have incomes below 250% of the federal poverty level. A smart default policy would lead to a mean $102.47 decrease in monthly premiums (95% CI, $103.84-$101.10), a mean $1960 reduction in individual annual medical deductibles (95% CI, $1991-$1928), and a $49.56 reduction in specialty prescription copays (95% CI, $49.77-$49.34). Conclusions and Relevance: The findings of this economic analysis suggest that a smart default policy could avoid defaulting lower-income marketplace enrollees to objectively inferior health care insurance plans and may lead to large reductions in lower-income enrollees' deductibles, copayments, and maximum out-of-pocket amounts. Implementation of a smart default policy could enable marketplace administrators to reduce the prevalence of underinsurance among lower-income marketplace enrollees.

Terminating Cost-Sharing Reduction Subsidy Payments: The Impact Of Marketplace Zero-Dollar Premium Plans On Enrollment.

The termination of cost-sharing reduction subsidy payments to insurers in 2017 by the administration of President Donald Trump resulted in a proliferation of Marketplace plans having zero-dollar premiums in 2018 and 2019. While it is known that lower premiums increase Marketplace enrollment, it is not clear whether a zero-price effect exists in which enrollment spikes when health insurance is free. We examined whether such an effect exists and found that increased availability of zero-dollar premium plans would have caused a 14.1 percent enrollment increase among lower-income Marketplace enrollees in 2019. If zero-dollar premium plans had not been available in 2019, our simulation results suggest that enrollment in the federally facilitated Marketplace would have decreased by roughly 200,000 enrollees. When we accounted for this zero-price effect, we found that variation in premiums above zero dollars was not associated with enrollment changes. These results suggest that efforts to insure lower-income populations should focus on making health insurance free to potential enrollees, instead of simply reducing premiums. However, increased enrollment in zero-dollar premium plans could result in increased cost sharing among Marketplace enrollees and increased federal outlays for Advance Premium Tax Credits.

Initial skill assessment of the California Harmful Algae Risk Mapping (C-HARM) system.

Toxic algal events are an annual burden on aquaculture and coastal ecosystems of California. The threat of domoic acid (DA) toxicity to human and wildlife health is the dominant harmful algal bloom (HAB) concern for the region, leading to a strong focus on prediction and mitigation of these blooms and their toxic effects. This paper describes the initial development of the California Harmful Algae Risk Mapping (C-HARM) system that predicts the spatial likelihood of blooms and dangerous levels of DA using a unique blend of numerical models, ecological forecast models of the target group, Pseudo-nitzschia, and satellite ocean color imagery. Data interpolating empirical orthogonal functions (DINEOF) are applied to ocean color imagery to fill in missing data and then used in a multivariate mode with other modeled variables to forecast biogeochemical parameters. Daily predictions (nowcast and forecast maps) are run routinely at the Central and Northern California Ocean Observing System (CeNCOOS) and posted on its public website. Skill assessment of model output for the nowcast data is restricted to nearshore pixels that overlap with routine pier monitoring of HABs in California from 2014 to 2015. Model lead times are best correlated with DA measured with solid phase adsorption toxin tracking (SPATT) and marine mammal strandings from DA toxicosis, suggesting long-term benefits of the HAB predictions to decision-making. Over the next three years, the C-HARM application system will be incorporated into the NOAA operational HAB forecasting system and HAB Bulletin.