Income Disparities in the Prevalence, Severity, and Costs of Co-occurring Chronic and Behavioral Health Conditions.

BACKGROUND: Behavioral health problems usually co-occur along with physical health problems, resulting in higher health care costs. These co-occurring conditions are likely to be more prevalent and serious among low income patients, affecting both the quality and costs of care. OBJECTIVE: To examine the prevalence, severity, and health care costs of co-occurring chronic and behavioral health conditions among low income people compared with higher income people. METHODS: Analysis of the 2011-2014 Medical Expenditure Panel Survey. Sample includes 146,000 persons aged 18-64 years. Regression analysis was used to examine how the combination of behavioral health conditions and chronic health conditions is associated with health care expenditures, and how this association differs by family income. RESULTS: (1) Comorbid behavioral health problems are more prevalent and serious among low income people with chronic conditions compared with higher income people; (2) among patients with co-occurring chronic and behavioral problems, average annual spending is greater among the low income patients ($9472) compared with high income patients ($7457); (3) higher costs among low income patients with co-occurring conditions reflects their poorer mental and physical health, relative to higher income patients. CONCLUSIONS: For many low income people, comorbid behavioral problems need to be understood in the social context in which they live. Simply screening low income people for behavioral health problems may not be sufficient unless there is greater understanding of the mechanisms that both cause and exacerbate chronic and behavioral health problems in the low income population.

Tobacco use and health insurance literacy among vulnerable populations: implications for health reform.

BACKGROUND: Under the Affordable Care Act (ACA), millions of Americans have been enrolling in the health insurance marketplaces. Nearly 20% of them are tobacco users. As part of the ACA, tobacco users may face up to 50% higher premiums that are not eligible for tax credits. Tobacco users, along with the uninsured and racial/ethnic minorities targeted by ACA coverage expansions, are among those most likely to suffer from low health literacy - a key ingredient in the ability to understand, compare, choose, and use coverage, referred to as health insurance literacy. Whether tobacco users choose enough coverage in the marketplaces given their expected health care needs and are able to access health care services effectively is fundamentally related to understanding health insurance. However, no studies to date have examined this important relationship. METHODS: Data were collected from 631 lower-income, minority, rural residents of Virginia. Health insurance literacy was assessed by asking four factual questions about the coverage options presented to them. Adjusted associations between tobacco use and health insurance literacy were tested using multivariate linear regression, controlling for numeracy, risk-taking, discount rates, health status, experiences with the health care system, and demographics. RESULTS: Nearly one third (31%) of participants were current tobacco users, 80% were African American and 27% were uninsured. Average health insurance literacy across all participants was 2.0 (SD 1.1) out of a total possible score of 4. Current tobacco users had significantly lower HIL compared to non-users (-0.22, p < 0.05) after adjustment. Participants who were less educated, African American, and less numerate reported more difficulty understanding health insurance (p < 0.05 each.) CONCLUSIONS: Tobacco users face higher premiums for health coverage than non-users in the individual insurance marketplace. Our results suggest they may be less equipped to shop for plans that provide them with adequate out-of-pocket risk protection, thus placing greater financial burdens on them and potentially limiting access to tobacco cessation and treatment programs and other needed health services.

Acquisitions of behavioral health treatment facilities from 2010 to 2021.

Private equity (PE) and other for-profit ownership of behavioral health (mental health and substance use) treatment facilities have become increasingly prevalent, but data on these acquisitions are not readily available. In this study, we describe a novel database that contains information on the universe of behavioral health acquisitions that occurred between 2010 and 2021. We found that the frequency of behavioral health facilities involved in acquisitions increased substantially, from 32 facilities in 2010 to 1330 in 2021. The total number of facilities involved in acquisitions was 2806. Most of these facilities provided outpatient services only (N = 2073) and offered only mental health services (N = 1428). Private equity-backed acquisitions accounted for around 60% of all acquisition activity (N = 1678 facilities PE, N = 1128 facilities other for-profit). 25% of acquired facilities were located within 20 miles of one another (N = 561), 50% occurred within 80 miles (N = 1403), and 75% occurred within 319 miles (N = 2104). Future research should evaluate the effects of this consolidation on behavioral healthcare access, quality, spending, and patient outcomes.

Health Literacy and Plan Choice: Implications for Medicare Managed Care.

BACKGROUND: Older adults with inadequate health literacy may have difficulty selecting optimal coverage when faced with multiple health insurance plans to choose from. OBJECTIVE: This study sought to examine how health literacy affects which Medicare Advantage plans seniors select. METHODS: We surveyed 311 Medicare beneficiaries who did not have concurrent Medicaid coverage. Participants chose from three Medicare Advantage plans: (1) lower-premium, less coverage; (2) higher-premium, more coverage; and (3) an intermediate option. Adjusted associations between health literacy, plan choice, and the importance of plan attributes in decision-making were tested using ordered and multinomial logistic regressions. KEY RESULTS: Beneficiaries with inadequate health literacy chose the lower-premium, less coverage plan over the higher-premium, more coverage option compared to beneficiaries with adequate health literacy (p < .05) perhaps because participants with inadequate health literacy tended to rank the importance of plan attributes differently than those with adequate health literacy (p < .05). CONCLUSIONS: This evidence suggests there may be a disconnect among those with inadequate health literacy between attributes that were ranked as important and the plans they chose, resulting in choices that are not consistent with their preferences. Beneficiaries with inadequate health literacy may be at increased risk of selecting plans that do not meet their health needs, resulting in reduced access and higher costs. Medicare and consumer groups should support interventions to raise literacy levels and those that reduce the reliance on literacy when plan shopping. [HLRP: Health Literacy Research and Practice. 2018;2(1):e40-e54.]. PLAIN LANGUAGE SUMMARY: We examined how health literacy affects seniors' choice of Medicare Advantage plans. Results indicate that beneficiaries with inadequate health literacy chose the lower-premium, less coverage plan over the higher-premium, more coverage option compared to beneficiaries with adequate health literacy. Beneficiaries with inadequate health literacy tended to rank the importance of plan attributes differently than those with adequate health literacy.