Employer-Sponsored Coverage Stabilized And Uninsurance Declined In The Second Year Of The COVID-19 Pandemic.

The health risks of COVID-19, combined with widespread economic instability in the US, spurred Congress to pass temporary measures to improve access to health insurance. Using data from the Household Pulse Survey, a high-frequency, population-based survey, we examined trends in health coverage during 2021 and early 2022 among nonelderly adults. We estimated that eight million people gained coverage during this period, primarily because of increases in Medicaid and other public coverage. Despite rising employment, rates of employer-sponsored coverage remained flat. In Medicaid expansion states, employment rates increased significantly among Medicaid enrollees. Our results suggest that when the public health emergency ends, many people currently enrolled in Medicaid might no longer be eligible, particularly in Medicaid expansion states. Policy makers and employers should be prepared to help people who lose Medicaid eligibility identify and navigate enrollment in alternative sources of health insurance, including both Affordable Care Act Marketplace and employer-sponsored coverage.

Are Integrated Plan Providers Associated With Lower Premiums on the Health Insurance Marketplaces?

As the health insurance industry becomes more consolidated, hospitals and health systems have started to enter the insurance business. Insurers are also rapidly acquiring providers. Although these "vertically" integrated plan providers are small players in the insurance market, they are becoming more numerous. The health insurance marketplaces (HIMs) offer a unique setting to study integrated plan providers relative to other insurer types because the HIMs were designed to promote competition. In this descriptive study, the authors compared the premiums of the lowest priced silver plans of integrated plan providers with other insurer types on the 2015 and 2016 HIMs. Integrated plan providers were associated with modestly lower premiums relative to most other insurer types. This study provides early insights into premium competition on the HIMs. Examining integrated plan providers as a separate insurer type has important policy implications because they are a growing segment of the marketplaces and their pricing behavior may influence future premium trends.

Insurer Competition In Federally Run Marketplaces Is Associated With Lower Premiums.

Federal subsidies for health insurance premiums sold through the Marketplaces are tied to the cost of the benchmark plan, the second-lowest-cost silver plan. According to economic theory, the presence of more competitors should lead to lower premiums, implying smaller federal outlays for premium subsidies. The long-term impact of the Affordable Care Act on government spending will depend on the cost of these premium subsidies over time, with insurer participation and the level of competition likely to influence those costs. We studied insurer participation and premiums during the first two years of the Marketplaces. We found that the addition of a single insurer in a county was associated with a 1.2 percent lower premium for the average silver plan and a 3.5 percent lower premium for the benchmark plan in the federally run Marketplaces. We found that the effect of insurer entry was muted after two or three additional entrants. These findings suggest that increased insurer participation in the federally run Marketplaces reduces federal payments for premium subsidies.

The financial burden from prescription drugs has declined recently for the nonelderly, although it is still high for many.

Prescription drug spending and pharmacy benefit design have changed greatly over the past decade. However, little is known about the financial impact these changes have had on consumers. We examined ten years of nationally representative data from the Medical Expenditure Panel Survey and describe trends in two measures of financial burden for prescription drugs: out-of-pocket drug costs as a function of family income and the proportion of all out-of-pocket health care expenses accounted for by drugs. We found that although the percentage of people with high financial burden for prescription drugs increased from 1999 to 2003, it decreased from 2003 to 2007, with a slight increase in 2008. The decline is evidence of the success of strategies to lower drug costs for consumers, including the increased use of generic drugs. However, the financial burden is still high among some groups, notably those with public insurance and those with low incomes. For example, one in four nonelderly people devote more than half of their total out-of-pocket health care spending to prescription drugs. These trends suggest that the affordability of prescription drugs under the future insurance exchanges will need to be monitored, as will efforts by states to increase prescription drug copayments under Medicaid or otherwise restrict drug use to reduce public spending.

VA pharmacy users: how they differ from other veterans.

OBJECTIVE: To compare users and nonusers of Veterans Affairs (VA) pharmacy services by age group. STUDY DESIGN: Cross-sectional. METHODS: We used data on sociodemographics, health status, and medical conditions from the Medical Expenditure Panel Survey (MEPS) to compare users and nonusers of VA pharmacies for medications. Data were pooled for 2003-2005 to ensure adequate sample sizes. Student t tests were used to compare the means for each variable, and all analyses were adjusted for the complex sample design of the MEPS. RESULTS: Among both nonelderly (18-64 years) and elderly (>or=65 years) veterans, a higher proportion who used VA pharmacy services versus those who did not use VA pharmacy services (1) were black (nonelderly: 17.7 % vs 7.4%, P <.001; elderly: 9.4% vs 4.7%, P <.001); (2) had no alternative insurance (nonelderly: 27.2% vs 4.8%, P <.001; elderly: 36.3% vs 19.9%, P <.001); (3) had lower incomes (nonelderly: 32.4% vs 11.5%, P <.001; elderly: 32.4% vs 25.4%, P = .01); (4) had less than a high school education (nonelderly: 13.0% vs 6.5%, P <.001; elderly: 27.5% vs 17.6%, P <.001); (5) were disabled; and (6) reported poorer health. A higher percentage of nonelderly users reported a mental health condition (31.6% vs 19.4%, P <.001). CONCLUSIONS: Veterans who use VA pharmacy services appear to be more ill than those who do not use VA pharmacy services. In addition, the VA appears to be a safety net for uninsured veterans who have mental health problems.

The medical expenditure panel survey: a national information resource to support healthcare cost research and inform policy and practice.

BACKGROUND: The Medical Expenditure Panel Survey (MEPS) collects detailed information regarding the use and payment for health care services from a nationally representative sample of Americans. The survey is designed to provide analysts with the data they need to support policy-relevant research on health care expenses, utilization, insurance coverage, and access in the United States and to provide policymakers with the results and data they need to make informed decisions. OBJECTIVES: This article summarizes the capacity of this broad-based and publicly available information resource to support research efforts directed towards achieving a better understanding of the dynamics of American healthcare and to better characterize its current state. METHODS: The MEPS comprises a nationally representative sample of the civilian noninstitutionalized population in the United States, and collects comprehensive data on individuals and their health care experiences over a span of 2 years. Household survey data are collected by means of computer-assisted personal interviews, and those data are supplemented by information collected directly from the medical providers used by survey participants. Insurance data are collected both from households and through a separate state and nationally representative survey of business establishments, which collects information on health insurance provided by United States employers. RESULTS: The MEPS has been used extensively in scientific publications and published reports, as well as by the Federal and state governments to examine the delivery and financing of healthcare in the United States. CONCLUSIONS: The analytical findings generated by the MEPS are key inputs to facilitate the development, implementation, and evaluation of policies and practices addressing health care in the United States and its related costs. Recent efforts to reconcile MEPS and the National Health Expenditure Accounts have the potential to provide an even more accurate and powerful data tool for research and policy analysis.

Wealth, income, and the affordability of health insurance.

There have been debates over how many uninsured people can afford insurance but refuse to purchase it. Examining the difference in asset holdings between the privately insured and the uninsured, we found that the difference in purchasing power is not fully revealed by income comparisons. Median income among the privately insured is 2.9 times that of the uninsured, but median wealth among those with private insurance is 23.2 times that of the uninsured. Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.

Financial burden of health care, 2001-2004.

Analysis of data from the Medical Expenditure Panel Survey (MEPS) shows that rising out-of-pocket expenses and stagnant incomes increased health spending's financial burden for families in 2001-2004, especially for the privately insured. High financial burdens among those with nongroup coverage increased by more than one-third. Despite evidence of increased cost sharing in private insurance plans, our analysis does not show that privately insured people paid a higher share of their total health care bill in 2004 compared to 2001. Financial burdens have increased to the point at which private insurance is no longer able to provide financial protection for an increasing number of families.

Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003.

CONTEXT: Policymakers as well as physicians need to understand how rapidly rising health care costs are affecting specific groups of patients. OBJECTIVE: To estimate the number and characteristics of individuals in the United States faced with very high financial burdens for health care. DESIGN, SETTING, AND POPULATION: Data from a nationally representative sample of civilian, noninstitutionalized US individuals younger than 65 years from the Medical Expenditure Panel Surveys were used to calculate 2 measures of financial burden as a function of tax-adjusted family income. Total burden included all out-of-pocket expenditures for health care services, including premiums. Health care services burden excluded premiums and, when applied to the insured population, was used to identify the underinsured. We defined the underinsured as insured persons with health care service burdens in excess of 10% of tax-adjusted family income. MAIN OUTCOME MEASURES: Total and health care services burdens exceeding 10% and 20% of family income in 1996 and 2003. RESULTS: In 2003, there were 48.8 million individuals (19.2%) living in families spending more than 10% of family income on health care, an increase of 11.7 million persons since 1996. Of these individuals, about 18.7 million (7.3%) were spending more than 20% of family income. In 2003, individuals with higher-than-average risk of incurring high total burdens included poor and low-income persons and those with nongroup coverage, aged 55 to 64 years, living in a non-metropolitan statistical area, in fair or poor health, having any type of limitation, or having a chronic medical condition. Applying our definition of underinsured to the insured population, an estimated 17.1 million persons younger than 65 years were underinsured in 2003, including 9.3 million persons with private employment-related insurance, 1.3 million persons with private nongroup policies, and 6.6 million persons with public coverage. CONCLUSIONS: Our analysis identifies patients at greatest risk of health-related financial burdens that may adversely affect their access and adherence to recommended treatments. Our study also highlights the high costs associated with nongroup health insurance policies.

Trends in prescription drug expenditures by Medicaid enrollees.

OBJECTIVE: As prescription drug expenditures consume an increasingly larger portion of Medicaid budgets, states are anxious to control drug costs without endangering enrollees' health. In this report, we analyzed recent trends in Medicaid prescription drug expenditures by therapeutic classes and subclasses. Identifying the fastest growing categories of drugs, where drugs are grouped into clinically relevant classes and subclasses, can help policymakers decide where to focus their cost containment efforts. METHODS: We used data from the Medical Expenditure Panel Survey linked to a prescription drug therapeutic classification system, to examine trends between 1996/1997 and 2001/2002 in utilization and expenditures for the noninstitutionalized Medicaid population. We separated aggregate trends into changes in population with use and changes in expenditures per user, and percent generic. We also highlighted differences within the Medicaid population, including children, adults, disabled, and elderly. RESULTS: We found rapid growth in expenditures for antidepressants, antipsychotics, antihyperlipidemics, antidiabetic agents, antihistamines, COX-2 inhibitors, and proton pump inhibitors and found evidence supporting the rapid take-up of new drugs. In some cases these increases are the result of increased expenditures per user and in other cases the overall growth also comes from an increase in the population with use. CONCLUSIONS: Medicaid programs may want to reassess their cost-containment policies in light of the rapid take-up of new drugs. Our analysis also identifies areas in which more information is needed on the comparative effectiveness of new versus existing treatments.

Health care expenditure burdens among adults with diabetes in 2001.

OBJECTIVE: High out-of-pocket costs can pose a significant burden on patients with chronic conditions such as diabetes and contribute to decreased treatment adherence. We examined financial burdens among adults with diabetes using nationally representative data. METHODS: estimated how frequently adults with diabetes live in families in which spending on health insurance premiums and health care services exceed a specified percentage of family-level after-tax disposable income. RESULTS: We found that adults with diabetes face greater risks of high burdens compared with adults with any other highly prevalent medical condition. Adults with diabetes have lower incomes and pay a higher share of total expenditures out-of-pocket compared with adults with heart disease, hypertension, and cancer. Among adults with diabetes, women, those who live in poverty, and those with coexisting conditions are more likely to bear high burdens. Among nonelderly adults, those with public coverage and the uninsured have greater risk of high burdens compared with those with private insurance. More than 23% of the uninsured and more than 20% of those with public coverage spend more than half of their disposable income on health care. Among the elderly, those with private nonemployment related insurance have the greatest risk of high burdens followed by those with Medicare only, those with private employment-related coverage, and those enrolled in Medicaid. Prescription medications and diabetic supplies account for 63% to 70% of out-of-pocket expenditures among the nonelderly and 62% to 69% among the elderly. CONCLUSIONS: Our study identifies the subpopulations among adults with diabetes who are more likely to have high burdens, so that intervention measures can be targeted to help reduce treatment noncompliance. Our analysis also emphasizes the role of medications and diabetic supplies in contributing to high out-of-pocket burdens.

Reconciling medical expenditure estimates from the MEPS and NHEA, 2002.

The Medical Expenditure Panel Survey (MEPS) and National Health Expenditure Accounts (NHEA) are often used for health care policy analysis and simulations because they contain comprehensive estimates of national health care expenditures. The NHEA are primarily based on aggregate provider revenue data, while MEPS is based on person-level data on health care expenditures. This article compares MEPS and NHEA expenditure estimates for 2002 and discusses the differences. When MEPS and the NHEA are adjusted to be on a consistent basis, their expenditure estimates differ by 13.8 percent.

The impact of SCHIP on insurance coverage of children.

In this paper we use the Medical Expenditure Panel Survey between 1996 and 2002 to investigate the impact of the State Children's Health Insurance Program (SCHIP) on insurance coverage for children. We explore a range of alternative estimation strategies, including instrumental variables and difference-in-trends models. We find that SCHIP had a significant impact in decreasing uninsurance and increasing public insurance for both children targeted by SCHIP and those eligible for Medicaid. With respect to changes in private coverage our results are less conclusive: some specifications resulted in no significant effect of SCHIP on private insurance coverage, while others showed significant decreases in private insurance. Associated estimates of SCHIP crowd-out had wide confidence intervals and were sensitive to estimation strategy.

Gender differences in drug use and expenditures in a privately insured population of older adults.

We examine gender differences in use and expenditures for prescription drugs among Medicare and privately insured older adults aged 65 and over, using data on a nationally representative sample of prescription drug purchases collected for the Medical Expenditure Panel Survey Household Component. Overall, women spent about $1,178 for drugs, about 17% more than the $1,009 in average expenditures by men. Older women constituted 50.7% of the population and had average annual aggregate expenditures for prescribed medicines of $6.93 billion compared to $5.77 billion for men. Women were more likely than men to use drugs from a number of therapeutic classes-analgesics, hormones and psychotherapeutic agents-and therapeutic subclasses-thyroid drugs, COX-2 inhibitors and anti-depressants. Women also had higher average prescriptions per user for a number of therapeutic classes-hormones, psychotherapeutic agents and analgesics-and therapeutic subclasses-anti-diabetic drugs and beta blockers. Prescribed medications are, arguably, the most important healthcare technology in preventing illness, disability, and death in older adults. It is critical that older women and men have proper access to prescribed medicines. Given the financial vulnerability of this priority population, particularly women, the expanded drug coverage available under the Medicare Modernization Act is of particular relevance in meeting this goal.

Tracking changes in eligibility and coverage among children, 1996-2002.

Data from the 1996 Medical Expenditure Panel Survey (MEPS) reveal that 4.7 million children were eligible for Medicaid but were uninsured. Numerous changes have occurred in the landscape for children's health insurance since then, including welfare reform and implementation of the State Children's Health Insurance Program (SCHIP). We use data from the 1996-2002 MEPS to track changes in the eligibility and coverage of children. As of 2002, uninsurance among children remained as much a problem of participation as one of eligibility. Nevertheless, we find evidence of dramatic improvements in program participation, reflecting the success of efforts to improve outreach, simplify enrollment, and increase retention.

Looking inside the nation's medicine cabinet: trends in outpatient drug spending by Medicare beneficiaries, 1997 and 2001.

We examine trends in outpatient prescription drug spending by the Medicare civilian, noninstitutionalized population in 1997 and 2001 using nationally representative data from the Medical Expenditure Panel Survey. We find that the 72 percent increase in drug spending over this period, in excess of price inflation for all goods and services, is primarily attributable to increases in the number of prescriptions per drug user and in the price per prescription. We also find, however, that an increase in the number of users is the primary reason for growth in a number of the fastest-growing subclasses of drugs.

The ABCs of children's health care: how the Medicaid expansions affected access, burdens, and coverage between 1987 and 1996.

The Medicaid poverty expansions were among the major health policy initiatives of the late 1980s. This paper examines changes over a nine-year period in access, burdens, and coverage among children eligible for Medicaid through the expansions. Among eligible children, the Medicaid expansions reduced rates of uninsurance, increased access to physicians, and reduced families' risk of bearing a heavy financial burden. Gaps remain, however, and expansion-eligible children are more likely than never-eligible children to have been uninsured, to have gone without a physician office visit, and to have lived in a family that spent at least 20% of family income on medical care.

Health care expenditure burdens among elderly adults: 1987 and 1996.

OBJECTIVES: Concerns about the health care expenditure burdens of elderly adults underlie the ongoing debate over expanding Medicare benefits and strengthening Medicare+Choice. We examine burdens for this population using data from the 1987 National Medical Expenditure Survey (NMES) and the 1996 Medical Expenditure Panel Survey (MEPS). METHODS: We estimate how frequently elderly adults live in families whose health expenditures exceed 20% or 40% of their after-tax disposable incomes. Our methodology reduces bias due to errors in income while providing an intuitive measure of exposure to the risk of high burdens. RESULTS: Despite rapid increases in medical care prices, the percentage of elderly adults facing burdens over 20% of disposable income remained essentially constant at 20.9% in 1987 and 22.9% in 1996. The percentage with burdens exceeding 40% of disposable income was 7.3% in 1987 and 7.9% in 1996. High expenditure burdens were more prevalent among elderly adults who were poorer, older, female, higher risk, and covered only by traditional Medicare. Medicaid coverage helped to reduce burdens among the elderly poor, yet incomplete Medicaid take-up in 1996 left approximately 1.3 million elderly adults eligible for Medicaid but covered only by traditional Medicare. CONCLUSIONS: Our results highlight the widespread prevalence of high health care expenditure burdens among elderly adults and the varying extent to which insurance coverage helped to protect them from rising health care expenditures between 1987 and 1996.

Mental health parity: what are the gaps in coverage?

BACKGROUND: Mental health benefits in private health insurance plans in the United States are typically less generous than benefits for physical health care services, driving reform efforts to achieve parity in coverage. While there is growing evidence about the effects such legislation would have on the utilization and cost of mental health services, less is known about the impact parity would have on reducing the risk of large out-of-pocket expenses that families would face in the event of mental illness. AIMS OF THE STUDY: We seek to understand the impact that mental health parity would have on the out-of-pocket burden that families would face in the event of mental illness. We focus in particular on variations in coverage across the privately insured population. METHODS: We compare out-of-pocket spending for hypothetical episodes of mental health treatment, first under current insurance coverage in the United States and then under a reform policy of full mental health parity. We exploit detailed informtion on actual health plan benefits using a nationally-representative sample of the privately insured population under age 65 from the 1987 National Medical Expenditure Survey (NMES) that has been carefully aged and reweighted to represent 1995 population and benefit characteristics. RESULTS: Our results show that existing benefits of the U.S. privately insured population under age 65 leave most people at risk of high out-of-pocket costs in the event of a serious mental illness. Moreover, the generosity of existing mental health benefits varies widely across subgroups, particularly across firm size. We find significantly lower out-of-pocket costs when simulating full parity coverage. However, our results show those with less generous mental health coverage tend to have less generous physical health coverage, as well. CONCLUSIONS: Parity would substantially increase generosity of mental health coverage for most of the privately insured population. The wide variation in the generosity of existing mental health benefits suggests that there are likely to be differential impacts from a parity mandate. Those with limited physical health coverage would still be at significant financial risk for catastrophic mental illness.