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2.
Am J Law Med ; 45(2-3): 202-223, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31722629

RESUMO

In the 21st century the opportunity for the public to comment to an administrative agency typically means an invitation to go to a website, type words into a box, and hit send. Many advocacy groups provide templates for people to submit a statement in support or opposition to specific proposals. However, standardized comments do not capture the voice of Medicaid. They do not share people's personal experiences and insights. This article describes how consumer advocates in Kentucky devised a strategy, their Secret Sauce, to help consumers participate in the public comment process that is now required for Section 1115 Medicaid demonstration waiver applications. It shows how advocates can help real people's voices be heard in the public comment process, not through templates but through a process that assists people to tell their own stories in their own words. This is Medicaid's voice, the stories of real people who rely on Medicaid. Medicaid's voice can help policy makers understand the real-life impact of policy choices they make. It can also provide relevant evidence for courts reviewing the Secretary's grant of a Section 1115 waiver. Medicaid's voice can also help build political momentum, bringing those who rely on Medicaid to the polls and into the political conversation about the future of Medicaid.


Assuntos
Participação da Comunidade , Defesa do Consumidor , Medicaid/legislação & jurisprudência , Narrativas Pessoais como Assunto , Humanos , Cobertura do Seguro/legislação & jurisprudência , Kentucky , Patient Protection and Affordable Care Act , Estados Unidos
6.
Med Care ; 57(10): 788-794, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31513138

RESUMO

BACKGROUND: Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. OBJECTIVES: To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. RESEARCH DESIGN: A retrospective cohort study. SUBJECTS: Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. MEASURES: Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. RESULTS: The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18-0.19] and returning insured (OR, 0.22; 95% CI, 0.22-0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01-2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. CONCLUSIONS: Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Continuidade da Assistência ao Paciente , Feminino , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/legislação & jurisprudência , Masculino , Medicaid/legislação & jurisprudência , Pessoa de Meia-Idade , Oregon , Estudos Retrospectivos , Estados Unidos
11.
Pediatrics ; 143(6)2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31092588

RESUMO

OBJECTIVES: Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans. METHODS: Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans. RESULTS: Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending. CONCLUSIONS: Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.


Assuntos
Transtorno do Espectro Autista/epidemiologia , Transtorno do Espectro Autista/terapia , Dedutíveis e Cosseguros/legislação & jurisprudência , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/legislação & jurisprudência , Transtorno do Espectro Autista/economia , Criança , Dedutíveis e Cosseguros/economia , Feminino , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Masculino , Programas Obrigatórios/economia , Estados Unidos/epidemiologia
12.
J Trauma Acute Care Surg ; 87(2): 491-501, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31095067

RESUMO

BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.


Assuntos
Patient Protection and Affordable Care Act , Procedimentos Cirúrgicos Operatórios/legislação & jurisprudência , Ferimentos e Lesões/terapia , Emergências , Humanos , Cobertura do Seguro/legislação & jurisprudência , Procedimentos Cirúrgicos Operatórios/mortalidade , Traumatologia/legislação & jurisprudência , Resultado do Tratamento , Estados Unidos , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/cirurgia
13.
PLoS One ; 14(5): e0217064, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31125366

RESUMO

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians-with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.


Assuntos
Transtorno do Espectro Autista/economia , Transtorno do Espectro Autista/terapia , Política de Saúde , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/economia , Política , Transtorno do Espectro Autista/epidemiologia , Necessidades e Demandas de Serviços de Saúde , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Estados Unidos
16.
Albany Law Rev ; 82(2): 533-54, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30990590

RESUMO

The Affordable Care Act (ACA) has been subject to considerable volatility, with perhaps the greatest blow being the rescission, as part of the 2017 Tax Cuts and Jobs Act, of the penalty for its individual mandate to have health insurance coverage. As a New Republic article noted, "we will now find out whether or not an individual mandate really is essential to health reform. And that will settle an old intra-Democratic fight that has been dormant for a decade." The author, Joel Dodge, noted that in the face of Republican efforts to repeal the ACA, "Obamacare defenders (myself included) rebutted these attacks by doubling down on the argument that the law's entire structure would collapse without a mandate." Yet, following the mandate's repeal, Dodge admitted: The mandate was also never much of a mandate to begin with. The Obama administration gave numerous exemptions from the mandate for hardship and other life circumstances. And at just $695 or 2.5 percent of household income, the mandate's penalty for going without insurance costs far less than the cost of actually buying insurance. In contrast, in Massachusetts, the state that pioneered health care reform, the penalty for going uninsured, when one is deemed to be able to afford coverage, is "50 per cent of the minimum insurance premium for creditable coverage available through the commonwealth health insurance connector for which the individual would have qualified during the previous year." As one national policy magazine noted, after the individual mandate was repealed, many Democratic legislators expressed support for enacting it in their states, but those efforts mostly faltered: "Health policy experts attribute the waning enthusiasm to the unpopularity of the individual mandate." This article traces the origin of the individual mandate, chronicles the efforts of some states to enact their own mandates, and concludes by questioning whether the mandate is either necessary or politic.


Assuntos
Reforma dos Serviços de Saúde/legislação & jurisprudência , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência , Governo Estadual , Humanos , Estados Unidos
18.
Nursing ; 49(4): 56-60, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30893207

RESUMO

Understanding different models of healthcare worldwide and examining the benefits and challenges of those systems can inform potential improvements in the US. This article compares healthcare coverage in the US and Japan with respect to legislation, healthcare system models, eligibility of coverage, financial expenditures, health resources, and quality of care.


Assuntos
Comparação Transcultural , Cobertura do Seguro , Seguro Saúde , Assistência à Saúde/organização & administração , Definição da Elegibilidade/legislação & jurisprudência , Gastos em Saúde , Recursos em Saúde , Humanos , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Japão , Modelos Organizacionais , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/legislação & jurisprudência , Programas Nacionais de Saúde/organização & administração , Qualidade da Assistência à Saúde , Estados Unidos
20.
Med Care ; 57(4): 245-255, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30807450

RESUMO

BACKGROUND: Decades-long efforts to require parity between behavioral and physical health insurance coverage culminated in the comprehensive federal Mental Health Parity and Addiction Equity Act. OBJECTIVES: To determine the association between federal parity and changes in mental health care utilization and spending, particularly among high utilizers. RESEARCH DESIGN: Difference-in-differences analyses compared changes before and after exposure to federal parity versus a comparison group. SUBJECTS: Commercially insured enrollees aged 18-64 with a mental health disorder drawn from 24 states where self-insured employers were newly subject to federal parity in 2010 (exposure group), but small employers were exempt before-and-after parity (comparison group). A total of 11,226 exposure group members were propensity score matched (1:1) to comparison group members, all of whom were continuously enrolled from 1 year prepolicy to 1-2 years postpolicy. MEASURES: Mental health outpatient visits, out-of-pocket spending for these visits, emergency department visits, and hospitalizations. RESULTS: Relative to comparison group members, mean out-of-pocket spending per outpatient mental health visit declined among exposure enrollees by $0.74 (1.40, 0.07) and $2.03 (3.17, 0.89) in years 1 and 2 after the policy, respectively. Corresponding annual mental health visits increased by 0.31 (0.12, 0.51) and 0.59 (0.37, 0.81) per enrollee. Difference-in-difference changes were larger for the highest baseline quartile mental health care utilizers [year 2: 0.76 visits per enrollee (0.14, 1.38); relative increase 10.07%] and spenders [year 2: $-2.28 (-3.76, -0.79); relative reduction 5.91%]. There were no significant difference-in-differences changes in emergency department visits or hospitalizations. CONCLUSIONS: In 24 states, commercially insured high utilizers of mental health services experienced modest increases in outpatient mental health visits 2 years postparity.


Assuntos
Gastos em Saúde , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Serviços de Saúde Mental/legislação & jurisprudência , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Transtornos Mentais
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