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.

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.

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.

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.

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.

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.

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.

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.

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.

Expansion coverage and preferential utilization of cancer surgery among racial and ethnic minorities and low-income groups.

BACKGROUND: The Affordable Care Act Medicaid expansion demonstrated inconsistent effects on cancer surgery utilization rates among racial and ethnic minorities and low-income Americans. This quasi-experimental study examines whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid programs. METHODS: A cohort of more than 81,000 patients 18 to 64 years of age who underwent cancer surgery were examined in Medicaid expansion versus nonexpansion states. This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File for the years 2012 to 2015. Poisson interrupted time series analysis were performed to examine the impact of Medicaid expansion on the utilization of cancer surgery for the uninsured overall, low-income persons, and racial minorities, adjusting for age, sex, Elixhauser comorbidity score, population-level characteristics, and provider-level characteristics. RESULTS: For persons from low-income ZIP codes, Medicaid expansion was associated with an immediate 24% increase in utilization (P = .002) relative to no significant change in nonexpansion states. No significant trends, however, were observed after the Affordable Care Act expansion for racial and ethnic minorities in expansion versus nonexpansion states. CONCLUSION: Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these findings highlight the need for additional investigation to uncover other factors that contribute to race-ethnic disparities in surgical cancer care.

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.

Affordable Care Act's Medicaid Expansion and Use of Regionalized Surgery at High-Volume Hospitals.

BACKGROUND: The Affordable Care Act (ACA)'s Medicaid expansion has increased access to surgical care overall. Whether it was associated with reduced disparities in use of regionalized surgery at high-volume hospitals (HVH) remains unknown. Quasi-experimental evaluations of this expansion were performed to examine the use of regionalized surgery at HVH among racial/ethnic minorities and low-income populations. STUDY DESIGN: Data from State Inpatient Databases (2012 to 2014), the American Hospital Association Annual Survey Database, and the Area Resource File from Health Resources and Services Administration, were used to examine 166,558 nonelderly (ages 18 to 64) adults at 468 hospitals, who underwent 1 of 4 regionalized surgical procedures in 3 expansion (KY, MD, NJ) and 2 nonexpansion states (NC, FL). Thresholds of HVH were defined using the top quintile of visits per year. Interrupted time series were performed to measure the impact of expansion on use rates of regionalized surgery at HVH overall, by race/ethnicity, and by income. RESULTS: Overall, ACA's expansion was not associated with accelerated use rates of regionalized surgical procedures at HVH (odds ratio [OR] 1.016, p = 0.297). Disparities in use of regionalized surgical procedures at HVH among ethnic/racial minorities and low-income populations were unchanged; minority vs white (OR 1.034 p = 0.100); low-income vs high-income (OR 1.034, p = 0.122). CONCLUSIONS: Early findings from ACA's Medicaid expansion revealed no impact on the use rates of regionalized surgery at HVH overall or on disparities among vulnerable populations. Although these results need ongoing evaluation, they highlight potential limitations in ACA's expansion in reducing disparities in use of regionalized surgical care.

The Affordable Care Act's Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery.

BACKGROUND: While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures. METHODS: The State Inpatient Database (2012-2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states. Discretionary procedures included non-emergent total knee and hip arthroplasty, while non-discretionary procedures included nine cancer surgeries. Mixed Poisson interrupted time series analyses were performed to determine the impact of the Affordable Care Act's Medicaid expansion on the number of discretionary procedures versus non-discretionary procedures provided among non-privately insured patients (Medicaid and uninsured patients) and privately insured patients. RESULTS: Analysis of the number of non-privately insured procedures showed an increase in discretionary procedures of +15.1% (IRR 1.15, 95% CI:1.11-1.19) vs -4.0% (IRR 0.96, 95% CI:0.94-0.99) and non-discretionary procedures of +4.1% (IRR 1.04, 95% CI:1.0-1.1) vs -5.3% (IRR 0.95, 95% CI:0.93-0.97) in expansion states compared to non-expansion states, respectively. Analysis of privately insured procedures showed no statistically meaningful change in discretionary procedures or non-discretionary procedures in either expansion or non-expansion states. CONCLUSION: In this multi-state evaluation, the Affordable Care Act's Medicaid expansion preferentially increased utilization of discretionary procedures versus non-discretionary procedures in expansion states compared to non-expansion states among non-privately insured patients. These preliminary findings suggest that increased Medicaid coverage may have contributed to the increased use of inpatient surgery for discretionary procedures.

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 well-being of long-term cancer survivors.

OBJECTIVES: To compare the well-being of long-term cancer survivors with that of US residents of similar age and demographic characteristics, patients recently diagnosed with cancer, and individuals with chronic illness. STUDY DESIGN: Retrospective observational study. METHODS: Using the Health and Retirement Study, a survey of US residents older than 50 years, we defined 4 cohorts: long-term cancer survivors (>4 years post diagnosis), individuals recently diagnosed with cancer (≤4 years post diagnosis), individuals with chronic illness, and US residents older than 50 years ("nationally representative cohort"). Well-being measures included self-reported health, utility, happiness, medical utilization and spending, employment, and earnings, and these measures were compared across cohorts, adjusting for survey year, demographic characteristics, smoking, and number of comorbidities. We imputed medical spending using the Medical Expenditure Panel Survey and the Medicare Current Beneficiary Survey. RESULTS: Long-term cancer survivors fared significantly better than those recently diagnosed with cancer, those with chronic illness, and individuals in the nationally representative cohort in the majority of well-being measures (P <.05), including fewer doctor visits, hospitalizations, and hospital nights; better utility and self-reported health; and greater likelihood of employment. Long-term cancer survivors had lower healthcare spending than those recently diagnosed with cancer (P <.01) and significantly greater happiness than the nationally representative cohort and those with chronic illness (P <.05). CONCLUSIONS: Although patients with cancer experience diminished well-being in the short term across a variety of measures, in the long term, cancer survivors do as well as or better than US residents of similar age and demographic characteristics. This finding is striking given that one might expect long-term cancer survivors to do worse than similar individuals without a history of cancer.

Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals.

BACKGROUND: The Affordable Care Act's Medicaid expansion has been heavily debated due to skepticism about Medicaid's ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure. STUDY DESIGN: We identified 67,685 nonelderly adults from the New York State Inpatient Database who underwent select cancer resections. High-quality hospitals were defined as high-volume or low-mortality hospitals. Disparity was defined as model-adjusted difference in percentage of patients receiving operations at high-quality hospitals by insurance type (Medicaid/uninsured vs privately insured) or by race (African American vs white). Levels of disparity were calculated quarterly for each comparison pair and then analyzed using interrupted time series to evaluate the impact of Medicaid expansion. RESULTS: Disparity in access to high-volume hospitals by insurance type was reduced by 0.97 percentage points per quarter after Medicaid expansion (p < 0.0001). Medicaid/uninsured beneficiaries had similar access to low-mortality hospitals as the privately insured; no significant change was detected around expansion. Conversely, racial disparity increased by 0.87 percentage points per quarter (p < 0.0001) in access to high-volume hospitals and by 0.48 percentage points per quarter (p = 0.005) in access to low-mortality hospitals after Medicaid expansion. CONCLUSIONS: Pre-Affordable Care Act Medicaid expansion reduced the disparity in access to surgical cancer care at high-volume hospitals by payer. However, it was associated with increased racial disparity in access to high-quality hospitals. Addressing racial barriers in access to high-quality hospitals should be prioritized.

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

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

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

BACKGROUND: Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities. STUDY DESIGN: From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series. RESULTS: The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion. CONCLUSIONS: Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.