Health Insurance Coverage And Access To Care Among LGBT Adults, 2013-19.

Historically, lesbian, gay, bisexual, and transgender (LGBT) adults have faced barriers to obtaining health insurance coverage, which have contributed to disparities in access to care and health outcomes. The Affordable Care Act (ACA) and the 2015 Supreme Court ruling on marriage equality had the potential to improve access to health insurance for LGBT people. Using data from the nationally representative Health Reform Monitoring Survey, we provide new evidence on trends in coverage and access to care for LGBT and non-LGBT adults between 2013 and 2019. In 2013 LGBT adults were significantly less likely than non-LGBT adults to have insurance coverage and more likely to report difficulty obtaining necessary medical care. Disparities in insurance coverage began to decline in 2014, when the main coverage provisions of the ACA went into effect. By 2017-19, coverage rates for LGBT adults were comparable to those of non-LGBT adults, although significant disparities in access remained.

The effect of income-based mandates on the demand for private hospital insurance and its dynamics.

We examine the effect of an income-based mandate on the demand for private hospital insurance and its dynamics in Australia. The mandate, known as the Medicare Levy Surcharge (MLS), is a levy on taxable income that applies to high-income individuals who choose not to buy private hospital insurance. Our identification strategy exploits changes in MLS liability arising from both year-to-year income fluctuations, and a reform where income thresholds were increased significantly. Using data from the Household, Income and Labour Dynamics in Australia longitudinal survey, we estimate dynamic panel data models that account for persistence in the decision to purchase insurance stemming from unobserved heterogeneity and state dependence. Our results indicate that being subject to the MLS penalty in a given year increases the probability of purchasing private hospital insurance by between 2 to 3 percent in that year. If subject to the penalty permanently, this probability grows further over the following years, reaching 13 percent after a decade. We also find evidence of a marked asymmetric effect of the MLS, where the effect of the penalty is about twice as large for individuals becoming liable compared with those going from being liable to not being liable. Our results further show that the mandate has a larger effect on individuals who are younger.

How well do doctors know their patients? Evidence from a mandatory access prescription drug monitoring program.

Many opioid control policies target the prescribing behavior of health care providers. In this paper, we study the first comprehensive state-level policy requiring providers to access patients' opioid history before making prescribing decisions. We compare prescribers in Kentucky, which implemented this policy in 2012, to those in a control state, Indiana. Our main difference-in-differences analysis uses the universe of prescriptions filled in the two states to assess how the information provided affected prescribing behavior. We find that a significant share of low-volume providers stopped prescribing opioids altogether after the policy was implemented, though this change accounted for a small share of the reduction in total volume. The most important margin of response was to prescribe opioids to fewer patients. Although providers disproportionately discontinued treating patients whose opioid histories showed the use of multiple providers, there were also economically meaningful reductions for patients without multiple providers and single-use acute patients.

The ACA's Impact On Racial And Ethnic Disparities In Health Insurance Coverage And Access To Care.

Large disparities in health insurance coverage and access to health services have long persisted in the US health care system. We considered how the insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups. Because coverage increased more for non-Hispanic blacks and Hispanics than for non-Hispanic whites, disparities in coverage have decreased. Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites.

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.

Health Reform and Retirement.

Objective: To analyze whether there was an increase in retirement or in part-time work among older workers after January 2014, when new health insurance coverage options became available because of the Affordable Care Act (ACA). Method: We analyze trends in retirement and part-time work for individuals aged 50-64 years in the basic monthly Current Population Survey from January 2008 through June 2016. We test for a break in trend in January 2014. We also test for differences in trends, both before and after 2014, in states that expanded their Medicaid programs in January 2014 under the ACA compared with those that did not. Results: We find that there was no change in the probability of retirement or part-time work among older workers in 2014 and later, either overall or in Medicaid expansion states relative to nonexpansion states. Discussion: Although many observers had predicted that an unintended consequence of health reform would be reduced labor supply, we find no evidence of this for older workers in the first 2.5 years after the law's major coverage provisions took effect.

Work, Health, And Insurance: A Shifting Landscape For Employers And Workers Alike.

We examined the complex relationship among work, health, and health insurance, which has been affected by changing demographics and employment conditions in the United States. Stagnation or deterioration in employment conditions and wages for much of the workforce has been accompanied by the erosion of health outcomes and employer-sponsored insurance coverage. In this article we present data and discuss the research that has established these links, and we assess the potential impact of policy responses to the evolving landscape of work and health. The expansion of insurance availability under the Affordable Care Act may have helped reduce the burden on employers to provide health insurance. However, the act's encouragement of wellness programs has uncertain potential to help contain the rising costs of employer-sponsored health benefits.

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.

Obesity and health expenditures: evidence from Australia.

Rising rates of obesity are a public health concern in every industrialized country. This study investigates the relationship between obesity and health care expenditure in Australia, where the rate of obesity has tripled in the last three decades. Now one in four Australians is considered obese, defined as having a body mass index (BMI, kg/m(2)) of 30 or over. The analysis is based on a random sample survey of over 240,000 adults aged 45 and over that is linked at the individual-level to comprehensive administrative health care claims for the period 2006-2009. This sub-population group has an obesity rate that is nearly 30% and is a major consumer of health services. Relative to the average annual health expenditures of those with normal weight, we find that the health expenditures of those with a BMI between 30 and 35 (obese type I) are 19% higher and expenditures of those with BMI greater than 35 (obese type II/III) are 51% higher. We find large and significant differences in all types of care: inpatient, emergency department, outpatient and prescription drugs. The obesity-related health expenditures are higher for obese type I women than men, but in the obese type II/III state, obesity-related expenditures are higher for men. When we stratify further by age groups, we find that obesity has the largest impact among men over age 75 and women aged 60-74 years old. In addition, we find that obesity impacts health expenditures not only through its link to chronic diseases, but also because it increases the cost of recovery from acute health shocks.

Preference heterogeneity and selection in private health insurance: the case of Australia.

A basic prediction of theoretical models of insurance is that if consumers have private information about their risk of suffering a loss there will be a positive correlation between risk and the level of insurance coverage. We test this prediction in the context of the market for private health insurance in Australia. Despite a universal public system that provides comprehensive coverage for inpatient and outpatient care, roughly half of the adult population also carries private health insurance, the main benefit of which is more timely access to elective hospital treatment. Like several studies on different types of insurance in other countries, we find no support for the positive correlation hypothesis. Because strict underwriting regulations create strong information asymmetries, this result suggests the importance of multi-dimensional private information. Additional analyses suggest that the advantageous selection observed in this market is driven by the effect of risk aversion, the ability to make complex financial decisions and income.

The price sensitivity of Medicare beneficiaries: a regression discontinuity approach.

We use 4 years of data from the retiree health benefits program of the University of Michigan to estimate the effect of price on the health plan choices of Medicare beneficiaries. During the period of our analysis, changes in the University's premium contribution rules led to substantial price changes. A key feature of this 'natural experiment' is that individuals who had retired before a certain date were exempted from having to pay any premium contributions. This 'grandfathering' creates quasi-experimental variation that is ideal for estimating the effect of price. Using regression discontinuity methods, we compare the plan choices of individuals who retired just after the grandfathering cutoff date and were therefore exposed to significant price changes to the choices of a 'control group' of individuals who retired just before that date and therefore did not experience the price changes. The results indicate a statistically significant effect of price, with a $10 increase in monthly premium contributions leading to a 2 to 3 percentage point decrease in a plan's market share.

Consumer-oriented health care reform strategies: a review of the evidence on managed competition and consumer-directed health insurance.

CONTEXT: For many years, leading health care reform proposals have been based on market-oriented strategies. In the 1990s, a number of reform proposals were built around the concept of "managed competition," but more recently, "consumer-directed health care" models have received attention. Although price-conscious consumer demand plays a critical role in both the managed competition and consumer-directed health care models, the two strategies are based on different visions of the health care marketplace and the best way to use market forces to achieve greater systemwide efficiencies. METHODS: This article reviews the research literature that tests the main hypotheses concerning the two policy strategies. FINDINGS: Numerous studies provide consistent evidence that consumers' health plan choices are sensitive to out-of-pocket premiums. The elasticity of demand appears to vary with consumers' health risk, with younger, healthier individuals being more price sensitive. This heterogeneity increases the potential for adverse selection. Biased risk selection also is a concern when the menu of health plan options includes consumer-directed health plans. Several studies confirm that such plans tend to attract healthier enrollees. A smaller number of studies test the main hypothesis regarding consumer-directed health plans, which is that they result in lower medical spending than do more generous plans. These studies find little support for this claim. CONCLUSIONS: The experiences of employers that have adopted key elements of managed competition are generally consistent with the key hypotheses underlying that strategy. Research in this area, however, has focused on only a narrow range of questions. Because consumer-directed health care is such a recent phenomenon, research on this strategy is even more limited. Additional studies on both topics would be valuable.

Employer-sponsored health insurance and the promise of health insurance reform.

The central role that employers play in financing health care is a distinctive feature of the U.S. health care system, and the provision of health insurance through the workplace has important implications well beyond its role as a source of health care financing. In this paper, we consider the "goodness of fit" of employer-sponsored health insurance (ESI) in the current economic and health insurance environments and in light of prospects for a vigorous national debate over the shape of health care reform. The main issue that we explore is whether ESI can have a viable role in health system reform efforts or whether such coverage will need to be significantly modified or even abandoned as reform seeks to address important issues in the efficient provision and equitable distribution of health insurance coverage.

Changes in racial disparities in access to coronary artery bypass grafting surgery between the late 1990s and early 2000s.

BACKGROUND: Racial disparities in medical care in the United States are pervasive and persistent. Minorities, African American patients in particular, have lower utilization rates for coronary artery bypass graft surgery (CABG) and, compared with white patients, they receive care from surgeons with worse records of performance. OBJECTIVES: We sought to examine the persistence of disparities in CABG care (overall access to surgery and access to high-quality surgeons) in recent years and the potential causes for declining disparities. MATERIALS AND METHODS: We undertook a retrospective analysis of data comparing access to CABG surgery and access to high-quality cardiac surgeons for white and black patients in the late 1990s and the early 2000s. Data used included the Medicare inpatient and physician part B claims and the New York State Cardiac Surgery Reports. A total of 24,087 Medicare fee-for-service patients undergoing CABG surgery between the years 1997-1999 and 23,048 patients undergoing CABG surgery between the years of 2001-2003 in New York State were studied. We measured the number of patients undergoing surgery by race and quality of surgeons measured by the surgeons' risk-adjusted mortality rates. CONCLUSIONS: Disparities have declined between the 2 periods. The decline seems to be associated with freed surgical capacity among all surgeons, although other factors may also present barriers, especially in terms of overall access to surgery. Despite the decline in disparities, gaps in care received by white and black patients remain.

Parity for whom? Exemptions and the extent of state mental health parity legislation.

Between 1997 and 2003, the share of workers subject to mental health parity laws greatly increased. But because of exemptions for self-insured firms and small firms, coverage is much lower than a simple tally of state mandates would suggest. Limits on the types of conditions covered further weaken these laws. This paper summarizes the extent and scope of state parity legislation in terms of the number of insured private-sector employees covered. It explicitly accounts for the Employee Retirement Income Security Act (ERISA) exemption for self-insured plans, exemptions for small employers, and the range of conditions covered by the law.

Immigrants and employer-sponsored health insurance.

OBJECTIVE: To investigate the factors underlying the lower rate of employer-sponsored health insurance coverage for foreign-born workers. DATA SOURCES: 2001 Survey of Income and Program Participation. STUDY DESIGN: We estimate probit regressions to determine the effect of immigrant status on employer-sponsored health insurance coverage, including the probabilities of working for a firm that offers coverage, being eligible for coverage, and taking up coverage. DATA EXTRACTION METHODS: We identified native born citizens, naturalized citizens, and noncitizen residents between the ages of 18 and 65, in the year 2002. PRINCIPAL FINDINGS: First, we find that the large difference in coverage rates for immigrants and native-born Americans is driven by the very low rates of coverage for noncitizen immigrants. Differences between native-born and naturalized citizens are quite small and for some outcomes are statistically insignificant when we control for observable characteristics. Second, our results indicate that the gap between natives and noncitizens is explained mainly by differences in the probability of working for a firm that offers insurance. Conditional on working for such a firm, noncitizens are only slightly less likely to be eligible for coverage and, when eligible, are only slightly less likely to take up coverage. Third, roughly two-thirds of the native/noncitizen gap in coverage overall and in the probability of working for an insurance-providing employer is explained by characteristics of the individual and differences in the types of jobs they hold. CONCLUSIONS: The substantially higher rate of uninsurance among immigrants is driven by the lower rate of health insurance offers by the employers of immigrants.

Can private companies contribute to public programs' outreach efforts? Evidence from California.

We studied an innovative outreach effort in California, which trains and certifies community organizations to help complete Medicaid and State Children's Health Insurance Program (SCHIP) applications. In this paper we provide a detailed description of participating organizations, the populations they serve, and their success at turning submitted applications into enrollments. We found that insurance brokers and income tax preparers-for-profit groups that are not typically associated with outreach-make important contributions to Medicaid and SCHIP in California. Brokers, in particular, help serve a hard-to-reach population: those on the higher end of the income eligibility thresholds.

Health insurance take-up by the near-elderly.

OBJECTIVE: To examine the effect of price on the demand for health insurance by early retirees between the ages of 55 and 64. DATA SOURCE: Administrative health plan enrollment data from a medium-sized U.S. employer. STUDY DESIGN: The analysis takes advantage of a natural experiment created by the firm's health insurance contribution policy. The amount the firm contributes toward retiree health insurance coverage depends on when a person retired and her years of service at that date. As a result of this policy, there is considerable variation in out-of-pocket premiums faced by individuals in the data. This variation is independent of the nonprice attributes of the health insurance plans offered and is plausibly exogenous to individual characteristics that are likely to affect the demand for insurance. A probit model is used to estimate the decision to take-up employer-sponsored health insurance by early retirees between the ages of 55 and 64. Demand for insurance is measured as a function of out-of-pocket premiums and a set of individual characteristics. PRINCIPAL FINDINGS: We find that price has a small but statistically significant effect on the decision to take up coverage. Estimated price elasticities range from -0.10 to -0.16, depending on the sample. CONCLUSIONS: The implied elasticities are comparable with results found in previous studies using very different data. Our estimates indicate that policy proposals for a Medicare buy-in or a nongroup tax credit will have a modest impact on take-up rates of near-elderly retirees.

The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.

Both the costs and benefits associated with extending health insurance coverage depend on the extent and exact ways in which health insurance affects the utilization of medical care. We review the literature relating to such effects with the goal of informing researchers interested in simulating the impact of policy initiatives aimed at achieving universal coverage. Overall, this literature is quite consistent in finding significant effects of insurance on all types of utilization. Insurance coverage increases outpatient utilization by roughly 1 visit per year for children and between 1 and 2 visits for adults. For both children and adults, these visits are associated with an increased receipt of preventive care. Insurance coverage also increases inpatient utilization for children and adults; for children, there is some evidence that insurance coverage reduces ambulatory care sensitive hospital admissions.

Health insurance reform and HMO penetration in the small group market.

This study uses data from several national employer surveys conducted between the late 1980s and the mid-1990s to investigate the effect of state-level underwriting reforms on HMO penetration in the small group health insurance market. We identify reform effects by exploiting cross-state variation in the timing and content of reform legislation and by using mid-sized and large employers, which were not affected by the legislation, as within-state control groups. While it is difficult to disentangle the effect of state reforms from other factors affecting HMO penetration in the small group markets, the results suggest a positive relationship between insurance market regulations and HMO penetration.