Stabilizing and Strengthening the Affordable Care Act: Opportunities for a New Administration.

For the past decade, the Affordable Care Act (ACA) has successfully reduced uninsurance and improved access to and affordability of health care services for millions of Americans. But the law was weakened when the Trump administration shortened the open enrollment period in the federal Marketplace, reduced outreach and enrollment funding, and revised the public charge rule, among other actions. The Biden administration will have the chance to reverse some of these changes and further strengthen the law to improve health care access and affordability. In this article, the author explores options for expanding access to affordable coverage and care for those who do not qualify for Medicaid or marketplace financial assistance and further discusses opportunities for increasing enrollment among those who are already eligible. The author also examines opportunities for expanding access to specific services, including reproductive health care, among those with insurance. Any attempts to modify or build on the ACA will likely be complicated by the ongoing coronavirus pandemic as well as slim Democratic majorities in the House and Senate, but regulatory solutions will likely be easier to achieve than those that require changes to federal law or state policy.

The role of external actors in shaping migrant health insurance in Thailand.

The role of external actors in national health policy in aid-independent countries has received relatively little attention in the literature, despite the fact that influence continues to be exerted once financial support is curtailed as countries graduate from lower income status. Focusing on a specific health policy in an aid-independent country, this qualitative study explores the role of external actors in shaping Thailand's migrant health insurance. Primary data were collected through in-depth interviews with eighteen key informants from September 2018 to January 2019. The data were analysed using thematic analysis, focusing on three channels of influence, financial resources, technical expertise and inter-sectoral leverage, and their effect on the different stages of the policy process. Given Thailand's export orientation and the importance of reputational effects, inter-sectoral leverage, mainly through the US TIP Reports and the EU carding decision, emerged as a very powerful channel of influence on priority setting, as it indirectly affected the migrant health insurance through efforts aimed at dealing with problems of human trafficking in the context of labour migration, especially after the 2014 coup d'état. This study helps understand the changed role external actors can play in filling health system gaps in aid-independent countries.

Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt.

OBJECTIVE: To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern U.S. states in which residents have high rates of diabetes. RESEARCH DESIGN AND METHODS: Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50-64 years, the percentage of women, Distressed Communities Index value, and rurality. RESULTS: In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states. CONCLUSIONS: ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt.

Ensuring HIV care to undocumented migrants in Israel: a public-private partnership case study.

BACKGROUND: Undocumented migrants in Israel, mostly originating from HIV endemic countries, are not covered by Israel's universal healthcare coverage. We initiated a Public-Private Partnership (PPP) to handle this public health and humanitarian challenge. The PPP venture included the Ministry of Health (MoH), pharmaceutical companies, pharmacies, and specialized HIV clinics, the Israeli HIV Medical Society (from the Israel Medical Association), and non-governmental organizations. This study describes the national policy process in conceptualizing and implementing access to HIV services for undocumented migrants through a PPP, and analyzes the preliminary results. METHODS: This case study describes the process of creating a temporary Public-Private Partnership to provide HIV care for undocumented migrants based on institutional records of the Department of Tuberculosis and AIDS (DTA) and memories and reflections from partners. This case was analyzed according to the OECD-DAC criteria for development assistance (relevance, effectiveness, efficiency, sustainability and impact). Demographic and serological data of patients referred between 2014 to 2018 were collected to monitor progress. and analyze preliminary medical and biological outcomes. Ethical approval was obtained from the Ministry of Health. RESULTS: Creating a policy to extend HIV care to undocumented migrants was a 15 year process that confronted several challenges within Israeli and international discourse, particularly concerning governmental response to the migration crisis. The use of a PPP model involving numerous stakeholders provided a solid, local feasibility demonstration that extending HIV care as a matter of policy would have positive implications for public health in Israel. During the first 2 years of the program (2014-2015), the MoH funded medical follow-up and the pharmaceutical companies provided antiretroviral treatment (ART) free of charge for only 100 patients at any given time, in addition to ART provided by the MoH for pregnant women. Since 2016, the MoH has fully covered this service and integrated it within the Israeli health system; this constitutes the major success of the PPP program. As of December 2018, the national program has monitored 350 patients and treated 316 (90.3%). The most prevalent disease present upon referral was Tuberculosis. CONCLUSIONS: To our knowledge, this study documents the first example of a successful PPP with government partnership in a high-income country to address undocumented migrants' lack of access to health services in general and HIV care in particular. In light of the intensification of North-South migration, this Israeli case study could be useful for other countries facing similar challenges. It also has lessons within Israel, as the country grapples with other health problems among uninsured communities.

Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act.

Importance: Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC. Objective: To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC. Design, Setting, and Participants: A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018. Main Outcomes and Measures: Changes in the percentage of patients with insurance. Results: A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36). Conclusions and Relevance: There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.

Insurance Loss in the Era of the Affordable Care Act: Association With Access to Health Services.

BACKGROUND: Every year, millions of Americans lose their health insurance and remain uninsured for various reasons, potentially impacting access to medical services. OBJECTIVE: To examine trends in health insurance loss in the periods shortly before and after implementation of Patient Protection and Affordable Care Act (ACA) and to assess the association of past-year health insurance loss with access to health services and medications. RESEARCH DESIGN AND SUBJECTS: Trends in health insurance loss were examined in 176,961 nonelderly adult participants of the National Health Interview Survey 2011-2017-a representative cross-sectional annual survey of US general population. Multivariable logistic regression models were used to examine access to health services and medications. MEASURES: Loss of private insurance or Medicaid in the past year; use of emergency room services and hospitalizations; contact with medical providers; affording medical care or medications; cost-related medication nonadherence. RESULTS: Private health insurance loss decreased from 3.9%-4.0% in 2011-2013 to 2.7% to 3.1% in 2014-2017 (P<0.001); Medicaid loss decreased from 8.5%-8.9% to 4.6%-6.4% in this period (P<0.001). Nevertheless, as late as 2017, ∼6 million uninsured adults reported having lost private insurance or Medicaid in the past year. Loss of either type of health insurance was associated with lower odds of accessing medical providers, but higher odds of not affording medical care and poor adherence to medication regimens to save costs. CONCLUSIONS: Implementation of ACA was associated with lower risk of health insurance loss. Nevertheless, health insurance loss remains a major barrier to accessing health services and prescribed medications.

Persisting Gaps in Coverage and Services of Illinois Women Who Acquired Insurance After Implementation of the Affordable Care Act.

OBJECTIVES: Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services. METHODS: We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education. RESULTS: We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03). CONCLUSIONS: The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.

Effects of the Affordable Care Act on Vascular Patient Amputation Rates in Arkansas.

BACKGROUND: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease. METHODS: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data. RESULTS: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05). CONCLUSIONS: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.

Health Reform and Higher Ed: Campuses as Harbingers of Medicaid Universality and Medicare Commonality.

Between 2010 and 2016, the percentage of uninsured higher education students dropped by more than half. All the Affordable Care Act's key access provisions contributed, but the most important factor appears to be the Medicaid expansion. This article is the first to highlight this phenomenon and ground it in data. It explores the reasons for this dramatic expansion of coverage, links it to theoretical frameworks, and considers its implications for the future of health reform. Drawing on Medicaid universality scholarship, I discuss potential consequences of including the educationally privileged in this historically stigmatized program. Extending this scholarship, I argue that the student experience and its reverberating effects portend support for emerging proposals to make Medicare a more common option. Woven into both analyses is the role of the Trump-era retrenchment, notably the administration's promotion of Medicaid "work or community engagement" requirements and of cheap, skimpy plans. Higher education students were an afterthought in the ACA's debates, and yet the law has profoundly impacted their coverage options. Students are now much more likely to have health insurance, and for it to be comprehensive. Looking to the next decade, the student experience harbingers support for both Medicaid universality and Medicare commonality.

The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics. QUESTIONS/PURPOSES: (1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state? METHODS: We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design. RESULTS: There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014. CONCLUSIONS: After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care. LEVEL OF EVIDENCE: Level III, therapeutic study.

States Can Now Add Work Requirements for Medicaid Recipients.

Health advocates fear new hurdles will leave thousands more uninsured.

Relative reductions in health care utilization among young adults before aging out of extended dependent coverage.

The 2010 Affordable Care Act extended dependent coverage for adult children up to age 26 in the USA. Since then, considerable studies have assessed its various impacts among young adults. However, little is known about whether there is any change in health care use when young adults age out of dependent coverage. This study examines health care consumption changes among young adults prior to their aging out process. I used data from a large insurance claim database and studied health care utilization of young adults under parents' coverage during a 2-year period in a difference-in-difference framework. I found that young adults had relative reductions in health services use, except ER visits, compared with individuals who stayed under parents' coverage. This pattern was the same for both male and females. Individuals with regular medical needs had greater relative reductions compared with those without regular medical needs. The relative reductions in health care use during the aging out process may have an important impact on young adults' health, especially for those with regular medical needs. More efforts could be made to help them maintain regular medical utilization during the transition.