Adherence to hormonal therapy after surgery among older women with ductal carcinoma in situ: Implications for breast cancer-related adverse health events.

BACKGROUND: Evidence from randomized clinical trials (RCTs) shows that receipt of hormonal therapy after surgery for estrogen receptor-positive ductal carcinoma in situ (DCIS) reduces the risk of DCIS and contralateral invasive breast cancer (IBC) but not death from breast cancer. RCTs examined homogeneous samples, and therefore whether this evidence can be generalized to diverse populations is unclear. METHODS: Population-based data from four state cancer registries (California, New Jersey, New York, and Texas) were analyzed on women aged 65 years and older newly diagnosed with DCIS who underwent surgery with or without radiation during the years 2006-2013. Registry records were merged with Medicare enrollment in Parts A and/or B and D (prescription drugs) and associated claims. Whether adherence to hormonal therapy was associated with adverse breast cancer-related health events was analyzed. RESULTS: Achieving excellent adherence did not affect death from breast cancer. In contrast, the risk of developing a subsequent breast tumor was 6.24 percentage points (breast-conserving surgery [BCS] with radiation therapy [RT]) and 10.54 percentage points (BCS alone) lower for women with excellent versus low adherence (p < .00001). For excellent versus good adherence, the reduced risk among women who had BCS with and without RT was approximately 3 and 5 percentage points, respectively. A similar pattern emerged for the risk of IBC among women who achieved excellent versus good or low adherence, whereas good versus low adherence comparisons were not significant. CONCLUSIONS: This analysis of a diverse population-based cohort of women with DCIS demonstrates that achieving excellent adherence to hormonal therapy is critical to minimizing the occurrence of developing subsequent breast tumors. PLAIN LANGUAGE SUMMARY: Our analysis of a diverse population-based cohort of women with ductal carcinoma in situ demonstrates that achieving excellent adherence to hormonal therapy is critical to minimizing the occurrence of developing subsequent breast tumors.

Nonclinical factors associated with the treatment of older women with newly diagnosed low-grade ductal carcinoma in situ.

BACKGROUND: Ductal carcinoma in situ (DCIS) is the most common form of noninvasive breast cancer and is associated with an excellent prognosis. As a result, there is concern about overdiagnosis and overtreatment of DCIS because most patients with DCIS are treated as though they have invasive breast cancer and undergo either breast-conserving surgery (BCS)-most commonly followed by radiation therapy (RT)-or mastectomy. Little research to date has focused on nonclinical factors influencing treatments for DCIS. METHODS: Population-based data were analyzed from five state cancer registries (California, Florida, New Jersey, New York, and Texas) on women aged 65 years and older newly diagnosed with DCIS during the years 2003 to 2014 using a retrospective cohort design and multinominal logistic modeling. The registry records with Medicare enrollment data and fee-for-service claims to obtain treatments (BCS alone, BCS with RT, or mastectomy) were merged. Surgeon practice structure was identified through physician surveys and internet searches. RESULTS: Patients of surgeons employed by cancer centers or health systems were less likely to receive BCS with RT or mastectomy than patients of surgeons in single specialty or multispecialty practices. There also was substantial geographic variation in treatments, with patients in New York, New Jersey, and California being less likely to receive BCS with RT or mastectomy than patients in Texas or Florida. CONCLUSIONS: These findings suggest nonclinical factors including the culture of the practice and/or financial incentives are significantly associated with the types of treatment received for DCIS. Increasing awareness and targeted efforts to educate physicians about DCIS management among older women with low-grade DCIS could reduce patient harm and yield substantial cost savings.

Vertical Integration Versus Physician Owners: Trends in Practice Structure Among Breast Cancer Surgeons.

OBJECTIVE: The objective of this study was to document changes in physician practice structure among surgeons who treat women with breast cancer. DESIGN: We merged cancer registry records from 5 large states with Medicare Part B claims to identify each surgeon who treated women with breast cancer. We added information from SK&A surveys and extensive internet searches. We analyzed changes in breast surgeons' practice structure over time. MEASURES: We assigned each surgeon-year a practice structure type: (1) small single-specialty practice; (2) single-specialty surgery or multispecialty practice with ownership in an ambulatory surgery center (ASC); (3) physician-owned hospital; (4) multispecialty; (5) employed. RESULTS: In 2003, nearly 74% of breast cancer surgeons belonged to small single-specialty practices. By 2014, this percentage fell to 51%. A shift to being employed (vertical integration) accounted for only a portion of this decline; between 2003 and 2014, the percentage of surgeons who were employed increased from 10% to 20%. The remainder of this decline is due to surgeons opting to acquire ownership in an ASC or a specialty hospital. Between 2003 and 2014, the percentage of surgeons with ownership in an ASC or specialty hospital increased from 4% to 17%. CONCLUSIONS: Dramatic changes in surgeon practice structure occurred between 2003 and 2014 across the 5 states we examined. The most notable was the sharp decline in the prevalence of the small single-specialty practice and large increases in the proportion of surgeons either employed or with ownership in ACSs or hospitals.

Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators.

OBJECTIVE: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS: Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS: PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.

How does expansion of public health insurance affect risk pools and premiums in the market for private health insurance? Evidence from Medicaid and the Affordable Care Act Marketplaces.

Private insurance market risk pools are likely to be directly affected by expansions of public insurance, in turn affecting premiums. We investigate the effects of Medicaid expansion on private health insurance markets using data on the plans offered through the health insurance "Marketplaces" (also known as Exchanges) established by the Affordable Care Act. We employ geographic matching to compare premiums for private plans in neighboring counties that straddle expansion and nonexpansion states and find that premiums of Marketplace plans are 11% lower in Medicaid expansion states, controlling for demographic and health characteristics as well as measures of health care access. These results are consistent with evidence on the composition of the private insurance risk pool in expansion versus nonexpansion states and associated differences in expected health spending.

The financial burden and health care utilization patterns associated with amnestic mild cognitive impairment.

INTRODUCTION: Individuals with amnestic mild cognitive impairment (aMCI) are at elevated risk of developing Alzheimer's disease (AD) dementia. METHODS: With data from the Aging, Demographics, and Memory Study, we used the Clinical Dementia Rating Sum of Boxes classifications to conduct a cross-sectional analysis assessing the relationship between cognitive state and various direct and indirect costs and health care utilization patterns. RESULTS: Patients with aMCI had less medical expenditures than patients with moderate and severe AD dementia (P < .001) and were also significantly less likely to have been hospitalized (P = .04) and admitted to nursing home (P < .001). Compared to individuals with normal cognition, patients with aMCI had significantly less household income (P = .018). DISCUSSION: Patients with aMCI had lower medical expenditures than patients with AD dementia. Poor cognitive status was linearly associated with lower household income, higher medical expenditures, higher likelihood of nursing and home care services, and lower likelihood of outpatient visits.

Family structure and the economic wellbeing of children in youth and adulthood.

An extensive literature on the relationship between family structure and children's outcomes consistently shows that living with a single parent is associated with negative outcomes. Few US studies, however, examine how a child's family structure affects outcomes for the child once he/she reaches adulthood. We directly examine, using the Panel Study of Income Dynamics, whether family structure during childhood is related to the child's economic wellbeing both during childhood as well as during adulthood. We find that living with a single parent is associated with the level of family resources available during childhood. This finding persists even when we remove time invariant factors within families. We also show that family structure is related to the child's education, marital status, and adult family income. Once we control for the child's demography and economic wellbeing in childhood, however, the associations into adulthood become trivial in size and statistically insignificant, suggesting that the relationship between family structure and children's long-term, economic outcomes is due in large part to the relationship between family structure and economic wellbeing in childhood.

Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19.

Importance: Primary care (PC) receipt is associated with better health outcomes. How telehealth expansion and internet speed are associated with PC use is unclear. Objective: To examine the association of telehealth and internet speed with PC use across sociodemographic determinants of health. Design, Setting, and Participants: This cohort study performed difference-in-differences regression of the change in in-person and telehealth PC visits between pre-COVID-19 public health emergency (PHE) (June 1, 2019, to February 29, 2020) and an initial (March 1, 2020, to May 31, 2020) and prolonged (March 1, 2020, to December 31, 2021) PHE period among continuously enrolled nonpregnant, nondisabled Wisconsin Medicaid beneficiaries aged 18 to 64 years. Data were analyzed from March 2022 to March 2023. Exposure: PHE-induced telehealth expansion. Main Outcomes and Measures: Change in PC telehealth (using Current Procedural Terminology codes) visits: (1) count; (2) visit share completed by telehealth; (3) percentage of PHE-induced visit decline offset by telehealth. High-speed internet (HSI) defined as living in a census block group with a median block maximum download speed of 940 megabits per second or greater (June 2020 Federal Communications Commission broadband data); other census block groups classified as low-speed internet (LSI). Results: In the total cohort of 172 387 participants, 102 989 (59.7%) were female, 103 848 (60.2%) were non-Hispanic White, 34 258 (19.9%) were non-Hispanic Black, 15 020 (8.7%) were Hispanic, 104 239 (60.5%) were aged 26 to 45 years, and 112 355 (66.0%) lived in urban counties. A total of 142 433 (82.6%) had access to HSI; 72 524 (42.1%) had a chronic condition. There was a mean (SD) of 0.138 (0.261) pre-PHE PC visits per month. In the pre-PHE period, visit rates were significantly higher for female than male participants, non-Hispanic White than non-Hispanic Black individuals, urban than rural residents, those with HSI than LSI, and patients with chronic disease than patients without. In the initial PHE period, female participants had a greater increase in telehealth visits than male participants (43.1%; 95% CI, 37.02%-49.18%; P < .001), share (2.20 percentage point difference [PPD]; 95% CI, 1.06-3.33 PPD; P < .001) and offset (6.81 PPD; 95% CI, 3.74-9.87 PPD; P < .001). Non-Hispanic Black participants had a greater increase in share than non-Hispanic White participants (5.44 PPD; 95% CI, 4.07-6.81 PPD; P < .001) and offset (15.22 PPD; 95% CI, 10.69-19.75 PPD; P < .001). Hispanic participants had a greater increase in telehealth visits than Non-Hispanic White participants (35.60%; 95% CI, 25.55%-45.64%; P < .001), share (8.50 PPD; 95% CI, 6.75-10.26 PPD; P < .001) and offset (12.93 PPD; 95% CI, 6.25-19.60 PPD; P < .001). Urban participants had a greater increase in telehealth visits than rural participants (63.87%; 95% CI, 52.62%-75.11%; P < .001), share (9.13 PPD; 95% CI, 7.84-10.42 PPD; P < .001), and offset (13.31 PPD; 95% CI; 9.62-16.99 PPD; P < .001). Participants with HSI had a greater increase in telehealth visits than those with LSI (55.23%; 95% CI, 42.26%-68.20%; P < .001), share (6.61 PPD; 95% CI, 5.00-8.23 PPD; P < .001), and offset (6.82 PPD; 95% CI, 2.15-11.49 PPD; P = .004). Participants with chronic disease had a greater increase in telehealth visits than those with none (188.07%; 95% CI, 175.27%-200.86%; P < .001), share (4.50 PPD; 95% CI, 3.58-5.42 PPD; P < .001), and offset (9.03 PPD; 95% CI, 6.01-12.04 PPD; P < .001). Prolonged PHE differences were similar. Differences persisted among those with HSI. Conclusions and Relevance: In this cohort study of Wisconsin Medicaid beneficiaries, greater telehealth uptake occurred in groups with higher pre-PHE utilization, except for high uptake among Hispanic and non-Hispanic Black individuals despite low pre-PHE utilization. HSI did not moderate disparities. These findings suggest telehealth and HSI may boost PC receipt, but will generally not close utilization gaps.

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost sharing reductions (CSRs) to low-income consumers on the Marketplaces. We link 2013-2015 All-Payer Claims Data to 2004-2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost sharing have higher levels of health care spending, controlling for past health care use. We estimate demand elasticities of total health care spending among this low-income population of approximately -0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.

Health and Healthcare Access for Essential, Nonessential, and Nonworkers During the COVID-19 Pandemic.

OBJECTIVE: The aim of the study is to describe sociodemographic characteristics, healthcare access, and health status of low-income essential, nonessential, and nonworkers during the COVID-19 pandemic. METHODS: Using survey data (2020-2021) from Wisconsin Medicaid enrollees ( N = 2528), we compared sociodemographics, healthcare access, and health status between essential, nonessential, and nonworkers. RESULTS: Essential workers had less consistent health insurance coverage and more problems paying medical bills than nonessential and nonworkers. They reported better health than nonessential and nonworkers. They reported fewer work-limiting conditions and less outpatient healthcare utilization than nonworkers but similar rates as nonessential workers. Essential workers reported masking less frequently than nonworkers but similar frequency to nonessential workers, and lower COVID-19 vaccine willingness than nonessential and nonworkers. CONCLUSIONS: Essential workers report better health, fewer protective behaviors, and more healthcare barriers than nonessential and nonworkers. Findings indicate essential worker status may be a social determinant of health.

The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres.

BACKGROUND: This study aimed to calculate costs and health-related quality of life of women with endometriosis-associated symptoms treated in referral centres. METHODS: A prospective, multi-centre, questionnaire-based survey measured costs and quality of life in ambulatory care and in 12 tertiary care centres in 10 countries. The study enrolled women with a diagnosis of endometriosis and with at least one centre-specific contact related to endometriosis-associated symptoms in 2008. The main outcome measures were health care costs, costs of productivity loss, total costs and quality-adjusted life years. Predictors of costs were identified using regression analysis. RESULTS: Data analysis of 909 women demonstrated that the average annual total cost per woman was €9579 (95% confidence interval €8559-€10 599). Costs of productivity loss of €6298 per woman were double the health care costs of €3113 per woman. Health care costs were mainly due to surgery (29%), monitoring tests (19%) and hospitalization (18%) and physician visits (16%). Endometriosis-associated symptoms generated 0.809 quality-adjusted life years per woman. Decreased quality of life was the most important predictor of direct health care and total costs. Costs were greater with increasing severity of endometriosis, presence of pelvic pain, presence of infertility and a higher number of years since diagnosis. CONCLUSIONS: Our study invited women to report resource use based on endometriosis-associated symptoms only, rather than drawing on a control population of women without endometriosis. Our study showed that the economic burden associated with endometriosis treated in referral centres is high and is similar to other chronic diseases (diabetes, Crohn's disease, rheumatoid arthritis). It arises predominantly from productivity loss, and is predicted by decreased quality of life.

Trends in Medicaid Enrollment and Disenrollment During the Early Phase of the COVID-19 Pandemic in Wisconsin.

Importance: After the federal public health emergency was declared in March 2020, states could qualify for increased federal Medicaid funding if they agreed to maintenance of eligibility (MOE) provisions, including a continuous coverage provision. The implications of MOE provisions for total Medicaid enrollment are unknown. Objective: To examine observed increases in Medicaid enrollment and identify the underlying roots of that growth during the first 7 months of the COVID-19 public health emergency in Wisconsin. Design Setting and Participants: This population-based cohort study compared changes in Wisconsin Medicaid enrollment from March through September 2020 with predicted changes based on previous enrollment patterns (January 2015-September 2019) and early pandemic employment shocks. The participants included enrollees in full-benefit Medicaid programs for nonelderly, nondisabled beneficiaries in Wisconsin from March through September 2020. Individuals were followed up monthly as they enrolled in, continued in, and disenrolled from Medicaid. Participants were considered to be newly enrolled if they enrolled in the program after being not enrolled for at least 1 month, and they were considered disenrolled if they left and were not reenrolled within the next month. Exposures: Continuous coverage provision beginning in March 2020; economic disruption from pandemic between first and second quarters of 2020. Main Outcomes and Measures: Actual vs predicted Medicaid enrollment, new enrollment, disenrollment, and reenrollment. Three models were created (Medicaid enrollment with no pandemic, Medicaid enrollment with pandemic economic circumstances, and longer Medicaid enrollment with a pandemic-induced recession), and a 95% prediction interval was used to express uncertainty in enrollment predictions. Results: The study estimated ongoing Medicaid enrollment in March 2020 for 792 777 enrollees (mean [SD] age, 20.6 [16.5] years; 431 054 [54.4%] women; 213 904 [27.0%] experiencing an employment shock) and compared that estimate with actual enrollment totals. Compared with a model of enrollment based on past data and incorporating the role of recent employment shocks, most ongoing excess enrollment was associated with MOE provisions rather than enrollment of newly eligible beneficiaries owing to employment shocks. After 7 months, overall enrollment had increased to 894 619, 11.1% higher than predicted (predicted enrollment 805 130; 95% prediction interval 767 991-843 086). Decomposing higher-than-predicted retention, most enrollment was among beneficiaries who, before the pandemic, likely would have disenrolled within 6 months, although a substantial fraction (30.4%) was from reduced short-term disenrollment. Conclusions and Relevance: In this cohort study, observed increases in Medicaid enrollment were largely associated with MOE rather than new enrollment after employment shocks. Expiration of MOE may leave many beneficiaries without insurance coverage.

Trends in the prevalence of short sleepers in the USA: 1975-2006.

STUDY OBJECTIVES: To determine (1) whether short sleep has increased over 31 years; (2) whether trends in short sleep differed by employment status; (3) which sociodemographic factors predict short sleep; and (4) how short sleepers spend their time. DESIGN: Time diaries from eight national studies conducted between 1975 and 2006. PATIENTS OR PARTICIPANTS: U.S. adults > or = 18 years. MEASUREMENTS AND RESULTS: Short sleepers were defined as those reporting < 6 hours of sleep in their time diary. Unadjusted percentages of short sleepers ranged from 7.6% in 1975 to 9.3% in 2006. The 1998-99 study had the highest odds of short sleep. The odds ratio for the 31-year period predicting short sleep was 1.14 (95% CI: 0.92, 1.50, P = 0.22), adjusting for age, sex, education, employment, race, marital status, income, and day of week. When stratified by employment, there was a significant increase for full-time workers (P = 0.05), who represented over 50% of participants in all studies, and a significant decrease for students (P = 0.01), who represented < 5% of participants. The odds of short sleep were lower for women, those > or = 65 years, Asians, Hispanics, and married people. The odds were higher for full-time workers, those with some college education, and African Americans. Short sleepers in all employment categories spent more time on personal activities. Short sleepers who were full- and part-time workers spent much more time working. CONCLUSIONS: Based on time diaries, the increase in the odds of short sleep over the past 31 years was significant among full-time workers only. Work hours are much longer for full-time workers sleeping < 6 hours.

The prevalence and determinants of antepartum mental health problems among women in the USA: a nationally representative population-based study.

Mental health problems disproportionately affect women, particularly during childbearing years. We sought to estimate the prevalence of antepartum mental health problems and determine potential risk factors in a representative USA population. We examined data on 3,051 pregnant women from 11 panels of the 1996-2006 Medical Expenditure Panel Survey. Poor antepartum mental health was defined by self report of mental health conditions or symptoms or a mental health rating of "fair" or "poor." Multivariate regression analyses modeled the odds of poor antepartum mental health; 7.8% of women reported poor antepartum mental health. A history of mental health problems increased the odds of poor antepartum mental health by a factor of 8.45 (95% CI, 6.01-11.88). Multivariate analyses were stratified by history of mental health problems. Significant factors among both groups included never being married and self-reported fair/poor health status. This study identifies key risk factors associated with antepartum mental health problems in a nationally representative sample of pregnant women. Women with low social support, in poor health, or with a history of poor mental health are at an increased risk of having antepartum mental health problems. Understanding these risk factors is critical to improve the long-term health of women and their children.

Quantifying the competitiveness of the electronic health record market and its implications for interoperability.

OBJECTIVE: The objective of this study was to quantify both the competitiveness of the EHR vendor market in the United States of America (US) and the degree of fragmentation of individual Medicare beneficiaries' medical records across the differing EHR vendors found in the US healthcare system. METHODS AND MATERIALS: We determined the Part A and Part B Medicare-expenditure weighted market shares of EHR vendors and estimated the rate of attestation of meaningful use (MU) for EHRs among Medicare Part A & B providers from 2011 to 2016. Based on these data we calculated the annual Herfindahl-Hirschman Index to quantify the competitiveness of the EHR market as well as the number of vendors individual Medicare beneficiaries' medical records were stored in for the period 2014-2016. RESULTS: We find that as of 2016 the EHR vendor environment was competitive but trending towards becoming highly concentrated soon. We also found that patient medical records were highly fragmented as only 4.5 % of expenditure-weighted individual Medicare beneficiaries had their MU medical records associated with a single vendor, while 19.8 % of expenditure-weighted beneficiaries had their MU medical records stored in 8 or more vendors. DISCUSSION: These results indicate that there are tradeoffs between EHR market competition, and the challenges associated with achieving interoperability across numerous competing vendors. CONCLUSION: Uncertainty of interoperability among different EHR vendors may make transmission of medical records among different providers challenging, mitigating the benefit of vendor competition. This highlights the critical importance of current interoperability efforts moving forward.

Access to health insurance at small establishments: what can we learn from analyzing other fringe benefits?

Workers employed at small establishments are less likely to be offered health insurance than workers in larger establishments. They are also paid less and are less likely to be offered pensions, paid sick leave, and paid vacations. Using the Medical Expenditure Panel Survey, we examine the relationship between health insurance and other components of workers' compensation. We also propose an approach for identifying and prioritizing the reasons why workers in small establishments are less likely to be offered employer health insurance by comparing the provision of health insurance and how it changes with establishment size to the provision of these other fringe benefits and how they change with establishment size. We find that workers in larger establishments are not only more likely to be offered health insurance by their employer, but also are more likely to be offered retirement and paid vacation benefits. The results of our benefits comparison analysis suggest an important role for administrative costs as an obstacle to offering health insurance.

A family perspective on population health: the case of child health and the family.

CONTEXT: This paper makes the case for a family perspective on population health and specifically focuses on how children's health can impact family health and well-being. OBJECTIVE: To review and synthesize the diverse set of papers that has examined the associations and linkages between children's health and family health. RESULTS: Based on the synthesis of the existing literature, additional research is needed that focuses on (1) the longitudinal impact of childhood chronic illness on the family using national samples, (2) the application of interdisciplinary methodologies to studying childhood chronic illness in the family, and (3) understanding the psychobiology of caring for a child with a chronic illness and the concordance of such measures with self-reported stress and burden. CONCLUSIONS: We propose a new integrated conceptual framework for better understanding the mechanisms that influence children's health and health care.

As Insurers Exit Affordable Care Act Marketplaces, So Do Consumers.

Insurer participation in the Marketplaces for individual health insurance has been lower than expected, with large declines among states using the HealthCare.gov platform for policy years 2017 and 2018. Using HealthCare.gov enrollment data, we examined how insurer exits from the Marketplaces affected consumers' decisions to reenroll-that is, to continue Marketplace participation-in policy years 2015-18. Insurer exit was associated with increased likelihood of consumer disenrollment from Marketplace coverage. The increase was twice as large for unsubsidized consumers (18.3 percentage points) than for consumers who received subsidies in the form of Advance Premium Tax Credits (8.7 percentage points) and was largely independent of premium increases measured using the lowest-cost silver plan available. However, premiums increased more in areas affected by insurer exits than in unaffected areas, contributing to increased disenrollment among unsubsidized consumers in policy years 2016-18. These findings suggest that maintaining insurer participation could encourage continued enrollment in the Marketplaces, while preserving competition to limit premium increases.

Zero-Premium Health Insurance Plans Became More Prevalent In Federal Marketplaces In 2018.

The Affordable Care Act established two federally funded subsidies-cost-sharing reductions and premium tax credits-available in the health insurance Marketplaces. In 2018 federal payments to insurers for cost-sharing reductions were terminated. Insurers responded by increasing plan premiums to account for the loss of these payments. Premiums for silver plans were increased more than those for other metal tiers because cost-sharing reductions are available only in silver plans, while premium tax credits can be applied across different metal tiers. One consequence of greater premium increases for silver plans was the increased availability and selection of plans with zero premiums for consumers. We examined the magnitude of this issue using plan selections through the federal Marketplaces during the open enrollment periods before (2017) and after (2018) the termination of payments. We found that zero-premium plan availability increased by 18.3 percentage points, selection increased by 7.9 percentage points, and selection conditional on having a zero-premium plan available increased by 8.8 percentage points. Were federal cost-sharing reduction payments to be restored, a reduction in availability and selection of zero-premium plans would likely occur, and more consumers could lose access to the plans.

Bariatric surgery among vulnerable populations: The effect of the Affordable Care Act's Medicaid expansion.

BACKGROUND: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery. METHODS: A total of 47,974 nonelderly adult bariatric surgical patients (ages 18-64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates. RESULTS: The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P < .001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states. CONCLUSION: The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery.