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Objective. To assess the impact of the Children's Health Insurance Program (CHIP) on the distribution of health insurance coverage for low-income children. Data Source. The primary data for the study were from the 1997, 1999, and 2002 National Survey of America's Families (NSAF), which includes a total sample of 62,497 children across all 3 years, supplemented with data from other data sources. Study Design. The study uses quasi-experimental designs and tests the sensitivity of the results to using instrumental variable and difference-in-difference approaches. A detailed Medicaid and CHIP eligibility model was developed for this study. Balanced repeated replicate weights were used to account for the complex sample of the NSAF. Descriptive and multivariate analyses were conducted. Principle Findings. The results varied depending on the approach utilized but indicated that the CHIP program led to significant increases in public coverage (14–20 percentage points); and declines in employer-sponsored coverage (6–7 percentage points) and in uninsurance (7–12 percentage points). The estimated share of CHIP enrollment attributable to crowd-out ranged from 33 to 44 percent. Smaller crowd-out effects were found for Medicaid-eligible children. Conclusions. Implementation of the CHIP program resulted in large increases in public coverage with estimates of crowd-out consistent with initial projections made by the Congressional Budget Office. This paper demonstrates that public health insurance expansions can lead to substantial reductions in uninsurance without causing a large-scale erosion of employer coverage. [ABSTRACT FROM AUTHOR]

Objective. This paper uses a unique database to examine premiums paid by beneficiaries for Medigap supplemental coverage. Average premiums charged by insurers are reported, as well as premiums by enrollee age and gender, and additional policy characteristics. Marginal prices for Medigap benefits are estimated using hedonic price regressions. In addition, the paper considers how additional policy characteristics and geographic differences in the use and cost of medical care affect premiums. Data Sources/Study Setting. A comprehensive database on premiums paid by beneficiaries for newly issued Medigap policies in the year 2000 along with state-level characteristics. Study Design. Hedonic pricing equations are used to estimate implicit prices for Medigap benefits. Data Collection/Extraction Methods. The Centers for Medicare & Medicaid Services contracted for the creation of a detailed database on Medigap premiums. Data were collected in three stages. First, letters were sent directly to insurers requesting premium data. Second, letters were directly to state insurance commissioner's offices requesting premium data. Last, each state insurance commissioner's office was visited to collect missing data. Principal Findings. With the exceptions of the part B deductible and drug benefit, Medigap supplemental insurance is priced consistent with the actuarial value of benefits offered under the standardized plans. Premiums vary substantially based on rating method, whether the policy is guaranteed issue, Medigap Select, or explicitly for smokers. Premiums increase with enrollee age, but do not vary between men and women. The relationship between premiums and enrollee age varies across rating methods. Attained-age policies show the strongest relationship between age and premiums, while community-rated premiums, by definition, do not vary with age. Medigap supplemental insurance premiums are higher in states with poorer health, greater utilization, and greater managed care penetration. Conclusions. Despite the high cost, Medigap plans are generally priced in accordance with the actuarial value of benefits. The primary exception is the drug benefit, which appears to be subject to substantial adverse selection. Benefits such as the part B deductible and at-home recovery benefit offer little value to consumers. Several states require insurers to community rate premiums. Such regulation has important implications for premiums, and research needs to consider the impact of such regulation on the Medigap market. [ABSTRACT FROM AUTHOR]

Objective. To measure the change in U.S. women and children's health insurance coverage as a result of welfare reform (i.e. the creation of Temporary Assistance for Needy Families or TANF) in 1996. Data Source. 1992–1999 longitudinal data from the Survey of Income and Program Participation (SIPP) merged with data on the timing of state implementation of welfare reform after 1996. Two key advantages of the SIPP data are that they permit matching type of insurance coverage to the welfare policy environment in each state in each month, and permit controlling for individual-level fixed effects. Study Design. We measure how much insurance coverage changed after welfare reform using a difference in differences method that eliminates the influence of time-invariant unobserved individual heterogeneity and of statewide trends in insurance coverage. Models also control for individual, state, and year fixed effects, individual-level characteristics such as education, age, and number of children, plus state-level variables such as real per capita income, real minimum wage, and Medicaid eligibility. Data Collection/Extraction Methods. We limit our analysis to the SIPP data specific to the month just completed prior to the interview; as a result, we have up to twelve observations for each individual in the SIPP. This paper uses pooled data from the 1992–1996 panels of the SIPP covering the period 1992–1999. Publicly available state identifiers permit the merger of state policies and macroeconomic variables with the SIPP. Principal Findings. TANF implementation is associated with an 8.1 percent increase in the probability that a welfare-eligible woman was uninsured. Welfare reform had less of an impact on the health insurance coverage of children. For example, TANF implementation was associated with a 3.0 percent increase in the probability that a welfare-eligible child lacked health insurance. Conclusions. An unintended consequence of welfare reform was to adversely impact the health insurance coverage of economically vulnerable women and children, and that this impact was several times larger than the previous literature implies. [ABSTRACT FROM AUTHOR]

Cogitates the challenges of studying the effects of managed care in the U.S. Changes to managed care plans in the medical care practice; Decline in the utilization management strategies; Impact of the reductions in selective contracting to health maintenance organizations.

The article discusses the role of state regulators and insurance companies in the U.S. in the U.S. Affordable Care Act to shape the markets and determine insurance plan affordability by referring to the article, Individual Market Health Plan Affordability after Cost Sharing Reduction Subsidy Cuts, published within the issue. Topics discussed include the affordability of the individual health insurance market, the termination of payments for cost-sharing reduction, and Medicaid expansion.

Objective: To examine the effects of hospital and insurer markets concentration on transaction prices for inpatient hospital services.Data Sources: Measures of hospital and insurer markets concentration derived from American Hospital Association and HealthLeaders-InterStudy data are linked to 2005-2008 inpatient administrative data from Truven Health MarketScan Databases.Study Design: Uses a reduced-form price equation, controlling for cost and demand shifters and accounting for possible endogeneity of market concentration using instrumental variables (IV) technique.Principal Findings: The findings suggest that greater hospital concentration raises prices, whereas greater insurer concentration depresses prices. A hypothetical merger between two of five equally sized hospitals is estimated to increase hospital prices by about 9 percent (p < .001). A similar merger of insurers would depress prices by about 15.3 percent (p < .001). Over the 2003-2008 periods, the estimates imply that hospital consolidation likely raised prices by about 2.6 percent, while insurer consolidation depressed prices by about 10.8 percent. Additional analysis using longer panel data and applying hospital fixed effects confirms the impact of hospital concentration on prices.Conclusion: The findings provide support for strong antitrust enforcement to curb rising hospital service prices and health care costs. [ABSTRACT FROM AUTHOR]

The author reflects on the impact of medicare coverage policies on health care utilization in the U.S. The author states that there are significant limitations to enforcement of coverage policies in the U.S. He notes that coverage decisions vary when there is no consensus about whether a particular procedure is effective. Furthermore, a suggestion to medicare carriers to focus their efforts on the elimination of forms of care that are inappropriate is presented.

Objective. To provide guidelines for identifying composite hypotheses and addressing the probability of false rejection for multiple hypotheses. Data Sources and Study Setting. Examples from the literature in health services research are used to motivate the discussion of composite hypothesis tests and multiple hypotheses. Methods. This article is a didactic presentation. Principal Findings. It is not rare to find mistaken inferences in health services research because of inattention to appropriate hypothesis generation and multiple hypotheses testing. Guidelines are presented to help researchers identify composite hypotheses and set significance levels to account for multiple tests. Conclusions. It is important for the quality of scholarship that inferences are valid: properly identifying composite hypotheses and accounting for multiple tests provides some assurance in this regard. [ABSTRACT FROM AUTHOR]

Determines the effects of competition for both Medicare and patients enrolled in health maintenance organizations on the quality decisions of hospitals in Southern California. Analysis of secondary discharge data from the Office of Statewide Health Planning and Development for the State of California; Formulation of competition measures; Increase in the degree of competition associated with hospital mortality rates.

Objective: The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers.Study Design: We compared insurance enrollment in states that did and did not allow tobacco surcharges, using a difference-in-difference approach to compare the policy effects among smokers and nonsmokers. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers.Data Collection: We linked data from two components of the Current Population Survey-the 2015 and 2019 Annual Social and Economic Supplement and the Tobacco Use Supplement, which we combined with data on marketplace plan premiums. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program.Principal Findings: Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P < .01) for every 10 percentage point increase in the tobacco surcharge.Conclusions: Tobacco use is the largest cause of preventable illness in the United States. State tobacco surcharge policy may have a substantial impact on whether tobacco users choose to remain insured and consequently their ability to receive care critical for preventing and treating tobacco-related disease. [ABSTRACT FROM AUTHOR]

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018.Study Design: A quasi-experimental differences-in-differences design using observational data.Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system. [ABSTRACT FROM AUTHOR]

Objective: To examine the effects of insurance and hospital market concentration on hospital patients' experience of care, as hospitals may compete on quality for favorable insurance contracts.Data Sources/study Setting: Secondary data for 2008-2015 on patient experience from Hospital Compare's patient survey data, hospital characteristics from the American Hospital Association (AHA) Annual Survey, and insurance market characteristics from HealthLeaders-InterStudy.Study Design: Hospital/year-level regressions predict each hospital's patient experience measure as a function of insurance and hospital market concentration and hospital fixed effects. The model is identified by longitudinal variation in insurance and hospital concentration.Data Collection/extraction Methods: Hospital/year-level data from Hospital Compare and the AHA merged by market/year to insurance and hospital concentration measures.Principal Findings: Changes in patient satisfaction are positively associated with increases in insurance concentration and negatively associated with increases in hospital concentration. Moving from a market with 20th percentile insurance concentration and 80th percentile hospital concentration to a market with 80th percentile insurance concentration and 20th percentile hospital concentration increases the share of patients that rated the hospital highly from 66.9 percent (95% CI: 66.5-67.2 percent) to 67.9 percent (95% CI: 67.5-68.3 percent) and the share of patients that definitely recommend the hospital from 69.7 percent (95% CI: 69.4-70.0 percent) to 70.8 percent (95% CI: 70.5-71.2 percent). The relationship for insurance concentration is stronger in more concentrated hospital markets, while the relationship for hospital concentration is stronger in less concentrated hospital markets.Conclusions: These findings add to the evidence on the harms of hospital consolidation but suggest that insurer consolidation may improve patient experience. [ABSTRACT FROM AUTHOR]

Objective: Spanish-preferring Medicare beneficiaries are underrepresented in national patient experience surveys. We test a method for improving their representation via higher response rates.Data Sources/study Setting: 2009-2010 Medicare CAHPS surveys; Medicare population.Study Design: We used surname and address to predict Spanish-language preference for a national sample of 177 139 beneficiaries. We randomized half of the 10 000 non-Puerto Rico beneficiaries with the highest predicted probabilities of Spanish preference (>10 percent) to bilingual mailings (intervention) and half to standard English-only mailings (control).Data Collection: Medicare CAHPS Survey data were collected through mail surveys with telephone follow-up of nonrespondents.Principal Findings: Mail response rate was higher for intervention (28.7 percent) than control (23.9 percent) (P < 0.0001); phone response rates among mail nonrespondents were similar in intervention and control arms (15.8 percent vs 15.7 percent, P = 0.90). Targeted bilingual mailings induced 6.5 percent of those who would not have responded to respond by mail and 54.0 percent of those who would have responded in English to respond in Spanish. Beneficiaries with greater Spanish probabilities showed greater increases in response rates, a higher proportion of responses in Spanish, and lower control response rates among.Conclusions: Targeted bilingual mailing of mixed-mode surveys using commonly available surname and address information can efficiently increase representation of this underrepresented group. [ABSTRACT FROM AUTHOR]

Objective: To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act.Data Source: Ten state primary care audit conducted in 2012/2013 and 2016.Study Design: CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type.Principal Findings: In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance.Conclusion: Appointment availability at CHCs improved after ACA implementation, without increased wait times. [ABSTRACT FROM AUTHOR]

Objective: To estimate and describe factors driving variation in spending for breast cancer patients within geographic region.Data Source: Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2009-2013.Study Design: The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient-level and physician-level variance in spending. Services associated with high spending physicians were estimated using linear regression.Data Extraction Method: A total of 20 818 women with a breast cancer diagnosis in 2010-2011.Principal Findings: We observed substantial between-patient and between-provider variation in spending following diagnosis and at the end-of-life. Immediately following diagnosis, 48% of between-patient and 31% of between-physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end-of-life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days.Conclusions: Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient-doctor discussions. [ABSTRACT FROM AUTHOR]

Objective: To compare medication adherence, cost, and utilization in Medicare beneficiaries attributed to nurse practitioners (NP) and primary care physicians (PCP).Data: Medicare Part A, B, and D claims and beneficiary summary file data, years 2009-2013.Study Design: We used propensity score-weighted analyses combined with logistic regression and generalized estimating equations to test differences in good medication adherence (proportion of days covered (PDC >0.8); office-based and specialty care costs; and ER visits.Data Extraction: Beneficiaries with prescription claims for anti-diabetics, renin-angiotensin system antagonists (RASA), or statins.Principal Findings: There were no differences in good medication adherence (PDC >0.8) between NP and PCP attributed beneficiaries taking anti-diabetics or RASA. Beneficiaries taking statins had a slightly higher probability of good adherence when attributed to PCPs (74.6% vs 75.5%; P < 0.05). NP attributed beneficiaries had lower office-based and specialty care costs and were less likely to experience an ER visit across all three medication cohorts (P < 0.01).Conclusions: Examining the impact of NP and PCP provided care on outcomes beyond the primary care setting is important to the Medicare program in general but will also help practices seeking to meet benchmarks under alternative payment models that incentivize higher quality and lower costs. [ABSTRACT FROM AUTHOR]

Objective: To measure the Medicaid undercount and analyze response error in the 2007‐2011 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). Data Sources/Study Setting: Medicaid Statistical Information System (MSIS) 2006‐2010 enrollment data linked to the 2007‐2011 CPS ASEC person records. Study Design: By linking individuals across datasets, we analyze false‐negative error and false‐positive error in reports of Medicaid enrollment. We use regression analysis to identify factors associated with response error in the 2011 CPS ASEC. Principal Findings: We find that the Medicaid undercount in the CPS ASEC ranged between 22 and 31% from 2007 to 2011. In 2011, the false‐negative rate was 40%, and 27% of Medicaid reports in CPS ASEC were false positives. False‐negative error is associated with the duration of enrollment in Medicaid, enrollment in Medicare and private insurance, and Medicaid enrollment in the survey year. False‐positive error is associated with enrollment in Medicare and shared Medicaid coverage in the household. Conclusions: Survey estimates of Medicaid enrollment and estimates of the uninsured population are affected by both false‐positive response error and false‐negative response error, and these response errors are non‐random. [ABSTRACT FROM AUTHOR]

Objective: To estimate health care utilization and costs incurred by homeless Veterans relative to nonhomeless Veterans and to examine the impact of a VA homelessness program on these outcomes.Data Sources/study Setting: Combined Department of Veterans Affairs (VA) administrative and Medicare claims data.Study Design: Observational study using longitudinal data from Veterans engaged with the VA system and enrolled in Medicare. Veterans with administrative evidence of homelessness at any point during 2006-2010 were matched on period of military service to Veterans with no evidence of homelessness.Principal Findings: Experience of homelessness was associated with 1.37 (95 percent CI = 1.34-1.40) and 0.16 (95 percent CI = 0.14-0.17) more outpatient encounters per quarter in VA and non-VA settings, respectively, and 1.31 (95 percent CI = 1.30-1.32) and 0.49 (95 percent CI = 0.48-0.49) more inpatient days per quarter in VA and non-VA hospitals, respectively. These were associated with higher costs. Relative to stably housed Veterans less than 65 years of age, those enrolled in a VA homelessness program had 94.4 percent (95 percent CI = 90.7 percent-98.1 percent) more VA outpatient visits but 5.5 percent (95 percent CI = 3.0 percent-7.9 percent) fewer Medicare outpatient visits.Conclusions: Homelessness was associated with an increase in VA and Medicare utilization and cost. A VA homelessness program decreased use of Medicare outpatient services. [ABSTRACT FROM AUTHOR]

Objective: To identify hospital/county characteristics and sources of regional heterogeneity associated with readmission penalties.Data Sources/study Setting: Acute care hospitals under the Hospital Readmissions Reduction Program from fiscal years 2013 to 2018 were linked to data from the Annual Hospital Association, Centers for Medicare and Medicaid Services, Medicare claims, Hospital Compare, Nursing Home Compare, Area Resource File, Health Inequity Project, and Long-term Care Focus. The final sample contained 3,156 hospitals in 1,504 counties.Data Collection/extraction Methods: Data sources were combined using Medicare hospital identifiers or Federal Information Processing Standard codes.Study Design: A two-level hierarchical model with correlated random effects, also known as the Mundlak correction, was employed with hospitals nested within counties.Principal Findings: Over a third of the variation in readmission penalties was attributed to the county level. Patient sociodemographics and the surrounding access to and quality of care were significantly associated with penalties. Hospital measures of Medicare volume, percentage dual-eligible and Black patients, and patient experience were correlated with unobserved area-level factors that also impact penalties.Conclusions: As the readmission risk adjustment does not include any community-level characteristics or geographic controls, the resulting endogeneity bias has the potential to disparately penalize certain hospitals. [ABSTRACT FROM AUTHOR]

Objective: The Medicare Modernization Act of 2004 allowed Medicare Advantage (MA) contracts to form provider networks in order to concentrate their patients among preferred providers. We focus on the skilled nursing facility (SNF) industry to assess patients' health when treating SNFs concentrate more patients from the same MA contract.Data Sources/study Setting: We use Medicare Beneficiary Summary File and Health, HEDIS, and the Minimum Data Set for patient attributes and OSCAR, LTCfocus.org, and Nursing Home Compare for SNF attributes. We include 1,069,436 MA enrollees newly admitted to SNF between 2012 and 2014.Study Design: Using a MA contract fixed-effect model, we examine the effect of prevalence of a patient's MA contract in the treating SNF on patient's health outcomes including 180-day survival, 30-day hospital readmission, 30-day home discharge, and nursing home length of stay. We use an Instrumental Variable (IV), the expected share of admissions in a SNF from patient's MA contract calculated using a McFadden choice model.Principal Findings: We find no relationship between SNF contract concentration and patients' outcomes after applying the IV.Conclusions: While MA plans appear to steer patients to specific SNFs, we do not observe significant returns to patient outcomes related to concentration. [ABSTRACT FROM AUTHOR]

Objective: To assess the issue of nonrepresentative sampling in Medicare Advantage (MA) risk adjustment.Data Sources: Medicare enrollment and claims data from 2008 to 2011.Data Extraction: Risk adjustment predictor variables were created from 2008 to 2010 Part A and B claims and the Medicare Beneficiary Summary File. Spending is based on 2009-2011 Part A and B, Durable Medical Equipment, and Home Health Agency claims files.Study Design: A propensity-score matched sample of Traditional Medicare (TM) beneficiaries who resembled MA enrollees was created. Risk adjustment formulas were estimated using multiple techniques, and performance was evaluated based on R2 , predictive ratios, and formula coefficients in the matched sample and a random sample of TM beneficiaries.Principal Findings: Matching improved balance on observables, but performance metrics were similar when comparing risk adjustment formula results fit on and evaluated in the matched sample versus fit on the random sample and evaluated in the matched sample.Conclusions: Fitting MA risk adjustment formulas on a random sample versus a matched sample yields little difference in MA plan payments. This does not rule out potential improvements via the matching method should reliable MA encounter data and additional variables become available for risk adjustment. [ABSTRACT FROM AUTHOR]

Objective: The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored.Data Sources/study Setting: Primary data collected through site visits to four private sector ACOs.Study Design: Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development.Data Collection: One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach.Principal Findings: The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided.Conclusions: We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system. [ABSTRACT FROM AUTHOR]

Objective: To assess frequency, type, and extent of behavioral health (BH) nonquantitative treatment limits (NQTLs) before and after implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).Data Sources: Secondary administrative data for Optum carve-out and carve-in plans.Study Design: Cross-tabulations and "two-part" regression models were estimated to assess associations of parity period with NQTLs.Data Collection/extraction Methods: Optum provided four proprietary BH databases, including 2008-2013 data for 40 carve-out and 385 carve-in employers from Optum's claims processing databases and 2010 data from interviews conducted by Optum's parity compliance team with 49 carve-out employers.Principal Findings: Preparity, carve-out plans required preauthorization for in-network inpatient/intermediate care; otherwise coverage was denied. Postparity, 73 percent would review later by request and half charged no penalty for late authorization. Outpatient visit authorization requirements virtually disappeared. For carve-out out-of-network inpatient/intermediate care, and for carve-ins, plans changed penalties to match medical service policies, but this did not necessarily lead to fewer requirements or lower penalties.Conclusion: After 2011, MHPAEA was associated with the transformation of BH care management, including much less restrictive preauthorization requirements, especially for in-network care provided by carve-out plans. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data.Data Sources/study Setting: One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool.Study Design: We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days.Principal Findings: With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs.Conclusions: The relationship between cost and quality depends on facility size and current level of performance. [ABSTRACT FROM AUTHOR]

Objective: To test whether underwriting modifies the effect of state-based incentives on individuals' purchase of long-term care insurance.Data Source: Health and Retirement Study (HRS), 1996-2012.Study Design: We estimated difference-in-difference regression models with an interaction of state policy indicators with individuals' probabilities of being approved for long-term care insurance.Data Extraction: We imputed probabilities of underwriting approval for respondents in the HRS using a model developed with underwriting decisions from two U.S. insurance firms. We measured the elasticity response to long-term care insurance price using changes in simulated after-tax price as an instrumental variable for premium price.Principal Findings: Tax incentives and Partnership programs increased insurance purchase by 3.62 percentage points and 1.8 percentage points, respectively, among those with the lowest risk (highest approval probability). Neither had any statistically significant effects among the highest risk individuals.Conclusions: We show that ignoring the effects of underwriting may lead to biased estimates of the potential state budget savings of long-term care insurance tax incentives. If the private market is to play a role in financing long-term care, policies need to address the underlying adverse selection problems. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of the 340B drug discount program on the site of cancer drug administration and cancer care spending in Medicare.Data Sources/study Setting: 2010-2013 Medicare claims data for a random sample of Medicare Fee-for-Service beneficiaries with cancer.Study Design: We identified the 340B effect using variation in the availability of 340B hospitals across markets. We considered beneficiaries from markets that newly gained a 340B hospital during the study period (new 340B markets) as the treatment group. Beneficiaries in markets with no 340B hospital were the control group. We used a difference-in-differences approach with market fixed effects.Data Collection: Secondary data analysis.Principal Findings: The probability of a patient receiving cancer drug administration in hospital outpatient departments (HOPDs) versus physician offices increased 7.8 percentage points more in new 340B markets than in markets with no 340B hospital. Per-patient spending on other cancer care increased $1,162 more in new 340B markets than in markets with no 340B hospital.Conclusions: The 340B program shifted the site of cancer drug administration to HOPDs and increased spending on other cancer care. As the program expands, continuing assessment of its impact on service utilization and spending would be needed. [ABSTRACT FROM AUTHOR]

Objective: To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant.Data Sources/study Setting: Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System.Data Collection/extraction Methods: The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents.Study Design: I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion.Principal Findings: I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization.Conclusions: Expanded Medicaid coverage for low-income adults has the potential to increase a woman's health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether enrollment in high-deductible health plans (HDHPs) led enrollees to choose lower-priced providers for office visits and laboratory tests.Study Setting: Claims data from more than 40 large employers.Study Design: We compared the change in price for office visits and laboratory tests for enrollees who switched to HDHPs versus enrollees who remained in traditional plans. We estimated separate models for enrollees who changed providers versus those who remained with the same provider to disentangle the effects of HDHPs on provider choice and negotiated prices.Data Collection: Claims data from 2004 to 2010 on 1.8 million enrollees.Principal Findings: After enrollment in HDHPs, 28 percent of enrollees changed physicians for office visits (compared to 19 percent in the Traditional Plan group, p < .01); however, this did not result in a statistically significant reduction in price for office visits. About 25 percent of enrollees changed providers for laboratory tests (compared to 23 percent in the Traditional Plan group, p < .01), resulting in savings of about $2.09 or a 12.8 percent reduction in price per laboratory test. We found that HDHPs had lower negotiated prices for office visits but not for laboratory tests.Conclusions: High-deductible health plan enrollment may shift enrollees to lower cost providers, resulting in modest savings. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of Kentucky's full rollout of the Affordable Care Act on disparities in access to care due to poverty.Data Source: Restricted version of the Behavioral Risk Factor Surveillance System (BRFSS) for Kentucky and years 2011-2015.Study Design: We use a difference-in-differences framework to compare trends before and after implementation of the Affordable Care Act (ACA) in health insurance coverage, several access measures, and health care utilization for residents in higher versus lower poverty ZIP codes.Principal Findings: Much of the reduction in Kentucky's uninsured rate appears driven by large uptakes in coverage from areas with higher concentrations of poverty. Residents in high-poverty communities experienced larger reductions, 8 percentage points (pp) in uninsured status and 7.5 pp in reporting unmet needs due to costs, than residents of lower poverty areas. These effects helped remove pre-ACA disparities in uninsured rates across these areas.Conclusion: Because we observe positive effects on coverage and reductions in financial barriers to care among those from poorer communities, our findings suggest that expanding Medicaid helps address the health care needs of the impoverished. [ABSTRACT FROM AUTHOR]

Objective: To examine the patterns of insurance coverage among nine Latino subgroups and assess heterogeneous effects of the Affordable Care Act (ACA) among these groups.Data Sources: American Community Survey (2010-2014).Study Design: We examined pre-ACA disparities in coverage using linear probability models. Then, we used interrupted time series and triple-difference models to evaluate coverage changes associated with the ACA and Medicaid expansion, respectively.Principal Findings: Pre-ACA coverage disparities between Latino subgroups were nearly 30 percentage points-larger than the gap between whites and Latinos as a whole. Coverage changes associated with the ACA and Medicaid expansion differed significantly between subgroups, with the largest gains among South Americans, Central Americans, and Mexicans.Conclusions: Latino subgroups show marked heterogeneity in baseline coverage rates and responses to the ACA. [ABSTRACT FROM AUTHOR]

Objective: To investigate the relationship between the percent uninsured in a county and expenditures associated with the typical emergency department visit.Data Sources: The Medical Expenditure Panel Survey linked to county-level data from the American Community Survey, the Healthcare Cost and Utilization Project, and the Area Health Resources Files.Study Design: We use a nationally representative sample of emergency department visits that took place between 2009 and 2013 to estimate the association between the percent uninsured in counties and the amount paid for a typical visit. Final estimates come from a diagnosis-level fixed-effects model, with additional controls for a wide variety of visit, individual, and county characteristics.Principal Findings: Among those with private insurance, we find that an increase of 1 percentage point in the county uninsurance rate is associated with a $20 increase in the mean emergency department payment. No such association is observed among visits covered by other insurance types.Conclusions: Results provide tentative evidence that the costs associated with high uninsurance rates spill over to those with insurance, but future research needs to replicate these findings with longitudinal data and methods before drawing causal conclusions. Recent data on changes in area uninsurance rates following the ACA's insurance expansions and subsequent changes in emergency department expenditures afford a valuable opportunity to do this. [ABSTRACT FROM AUTHOR]

Objective: Evaluating the potential of the high-dimensional propensity score (HDPS) to control for residual confounding in studies analyzing quality of care based on administrative health insurance data.Data Source: Secondary data from 2004 to 2009 from three German statutory health insurance providers.Study Design: We conducted a retrospective cohort study in patients with elective percutaneous coronary interventions (PCIs) and compared the mortality risk between the in- and outpatient setting using Cox regression. Adjustment for predefined confounders was performed using conventional propensity score (PS) techniques. Further, an HDPS was calculated based on predefined and empirically selected confounders from the database.Principal Findings: Conventional PS methods showed a decreased mortality risk for outpatient compared to inpatient PCIs, while trimming of patients with nonoverlap in the HDPS distribution and weighting resulted in a comparable risk. Most comorbidities were less prevalent in the HDPS-trimmed population compared to the original one.Conclusion: The HDPS methodology may reduce residual confounding by rendering the studied cohort more comparable through restriction. However, results cannot be generalized for the entire study population. To provide unbiased results, full assessment of all unmeasured confounders from proxy information in the database would be necessary. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of Enroll America's field outreach activities on the number of individuals enrolled in Marketplace coverage during the first open enrollment period.Data Sources/study Setting: Marketplace enrollment for the initial open enrollment period linked with data on Enroll America's field activities and baseline local-area demographic, economic, and health services characteristics.Study Design: We used a quasi-experimental design, comparing Marketplace enrollment during the first open enrollment period in local areas drawn from Enroll America field states to a comparison group of local areas drawn from states that were not served by Enroll America's field effort, but that otherwise match up well with Enroll America states.Principal Findings: We find evidence of a large, positive effect of Enroll America's field outreach on Marketplace enrollment in non-Medicaid expansion states. Across model specifications, the Enroll America effects on Marketplace enrollment ranged between 10 and 15 percent, with most estimates statistically significant at the 5 percent level.Conclusions: Enroll America played an important role in the success of individual states' efforts to boost Marketplace enrollment. Enroll American's evidence-driven, grassroots approach could serve as a model for others interested in conducting similar outreach campaigns for Affordable Care Act-related coverage. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of the 2006 Massachusetts health reform, the model for the Affordable Care Act, on short-term enrollment and utilization in the unsubsidized individual health insurance market.Data Source: Seven years of administrative and claims data from Harvard Pilgrim Health Care.Research Design: We employed pre-post survival analysis and an interrupted time series design to examine changes in enrollment length, utilization patterns, and use of elective procedures (discretionary inpatient surgeries and infertility treatment) among nonelderly adult enrollees before (n = 6,912) and after (n = 29,207) the MA reform.Principal Findings: The probability of short-term enrollment dropped immediately after the reform. Rates of inpatient encounters (HR = 0.83, 95 percent CI: 0.74, 0.93), emergency department encounters (HR = 0.85, 95 percent CI: 0.80, 0.91), and discretionary inpatient surgeries (HR = 0.66 95 percent CI: 0.45, 0.97) were lower in the postreform period, whereas the rate of ambulatory visits was somewhat higher (HR = 1.04, 95 percent CI: 1.00, 1.07). The rate of infertility treatment was higher after the reform (HR = 1.61, 95 percent CI: 1.33, 1.97), driven by women in individual (vs. family) plans. The reform was not associated with increased utilization among short-term enrollees.Conclusions: MA health reform was associated with a decrease in short-term enrollment and changes in utilization patterns indicative of reduced adverse selection in the unsubsidized individual market. Adverse selection may be a problem for specific, high-cost treatments. [ABSTRACT FROM AUTHOR]

Objective: To examine state and community factors that contributed to geographic variation in qualified health plan selection during the first open enrollment period.Data Sources/study Setting: Administrative data on qualified health plan selections at the ZIP code area merged with survey estimates from the American Community Survey.Study Design: Descriptive and regression analyses.Data Collection/extraction Methods: Data were generated by healthcare.gov and from a household survey.Principal Findings: Thirty-one percent of the variation in qualified health plan selection ratios resulted from between-state differences, and the rest was driven by local area differences. Education, language, age, gender, and the ethnic composition of communities contributed to disparate levels of plan selection. Medicaid expansion states had a qualified health plan selection ratio that was 4.4 points lower than non-Medicaid expansion states, controlling for covariates.Conclusions: Our results suggest community-level differences in the intensity or receptiveness to outreach and enrollment activities during the first open enrollment period. [ABSTRACT FROM AUTHOR]

Background: Extensive evidence documents geographic variation in spending, but limited research assesses geographic variation in quality, particularly among commercially insured enrollees.Objective: To measure geographic variation in quality measures, correlation among measures, and correlation between measures and spending for commercially insured enrollees.Data Source: Administrative claims from the 2007-2009 Truven MarketScan database.Methods: We calculated variation in, and correlations among, 10 quality measures across 306 Hospital Referral Regions (HRRs), adjusting for beneficiary traits and sample size differences. Further, we created a quality index and correlated it with spending.Results: The coefficient of variation of HRR-level performance ranged from 0.04 to 0.38. Correlations among quality measures generally ranged from 0.2 to 0.5. Quality was modestly positively related to spending.Conclusion: Quality varied across HRRs and there was only a modest geographic "quality footprint." [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women.Data Sources: Individual-level data on 600,000 women age 19-64 from the CDC's Behavioral Risk Factor Surveillance System.Study Design: Twenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate.Principal Findings: Difference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women.Conclusions: Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization. [ABSTRACT FROM AUTHOR]

Objective: To examine the role of patient, hospital, and community characteristics on racial and ethnic disparities in in-hospital postsurgical complications.Data Sources: Healthcare Cost and Utilization Project, 2011 State Inpatient Databases; American Hospital Association Annual Survey of Hospitals; Area Health Resources Files; Centers for Medicare & Medicaid Services Hospital Compare database.Methods: Nonlinear hierarchical modeling was conducted to examine the odds of patients experiencing any in-hospital postsurgical complication, as defined by Agency for Healthcare Research and Quality Patient Safety Indicators.Principal Findings: A total of 5,474,067 inpatient surgical discharges were assessed using multivariable logistic regression. Clinical risk, payer coverage, and community-level characteristics (especially income) completely attenuated the effect of race on the odds of postsurgical complications. Patients without private insurance were 30 to 50 percent more likely to have a complication; patients from low-income communities were nearly 12 percent more likely to experience a complication. Private, not-for-profit hospitals in small metropolitan or micropolitan areas and higher nurse-to-patient ratios led to fewer postsurgical complications.Conclusions: Race does not appear to be an important determinant of in-hospital postsurgical complications, but insurance and community characteristics have an effect. A population-based approach that includes improving the socioeconomic context may help reduce disparities in these outcomes. [ABSTRACT FROM AUTHOR]

Objective To identify roles physicians assumed as part of new health care delivery models and related strategies that facilitated physician engagement across 21 Health Care Innovation Award ( HCIA) programs. Data Sources Site-level in-depth interviews, conducted from 2014 to 2015 ( N = 672) with program staff, leadership, and partners (including 95 physicians) and direct observations. Study Design NORC conducted a mixed-method evaluation, including two rounds of qualitative data collected via site visits and telephone interviews. Data Collection/Extraction Methods We used qualitative thematic coding for data from 21 programs actively engaging physicians as part of HCIA interventions. Principal Findings Establishing physician champions and ensuring an innovation-values fit between physicians and programs, including the strategies programs employed, facilitated engagement. Among engagement practices identified in this study, tailoring team working styles to meet physician preferences and conducting physician outreach and education were the most common successful approaches. Conclusions We describe engagement strategies derived from a diverse range of programs. Successful programs considered physicians' values and engagement as components of process and policy, rather than viewing them as exogenous factors affecting innovation adoption. These types of approaches enabled programs to accelerate acceptance of innovations within organizations. [ABSTRACT FROM AUTHOR]

Objectives: To conduct a systematic literature review of selected major provisions of the Affordable Care Act (ACA) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the immediate and long-term effects of the ACA. We conclude with a summary and offer a research agenda for future studies.Study Design: We identified relevant articles from peer-reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identified reports in the "gray literature" disseminated by government agencies and other organizations.Principal Findings: Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provision, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets.Conclusions: The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will provide further insights as to whether the ACA has been successful in achieving its goals. [ABSTRACT FROM AUTHOR]

Objective: To examine the extent to which accountable care organizations (ACOs) formally incorporate postacute care providers.Data Sources: The National Survey of ACOs (N = 269, response rate 66 percent).Study Design: We report statistics on ACOs' formal inclusion of postacute care providers and the organizational characteristics and clinical capabilities of ACOs that have postacute care.Principal Findings: Half of ACOs formally include at least one postacute service, with inclusion at higher rates in ACOs with commercial (64 percent) and Medicaid contracts (70 percent) compared to ACOs with Medicare contracts only (45 percent). ACOs that have a formal relationship with a postacute provider are more likely to have advanced transition management, end of life planning, readmission prevention, and care management capabilities.Conclusions: Many ACOs have not formally engaged postacute care, which may leave room to improve service integration and care management. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits.Data Sources: West Virginia Medicaid enrollment and claims data from 2005 to 2010.Study Design: We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps.Data Collection: Data were obtained from the West Virginia Bureau for Medical Services.Principal Findings: We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan. [ABSTRACT FROM AUTHOR]

Objective: To estimate the impact of different forms of Medicaid managed care (MMC) delivery on racial and ethnic disparities in utilization.Data Source: Longitudinal, administrative data on 101,649 children in Kentucky continuously enrolled in Medicaid between January 1997 and June 1999. Outcomes considered are monthly professional, outpatient, and inpatient utilization.Study Design: We apply an intent-to-treat, instrumental variables analysis using the staggered geographic implementation of MMC to create treatment and control groups of children.Principal Findings: The implementation of MMC reduced monthly professional visits by a smaller degree for non-whites than whites (3.8 percentage points vs. 6.2 percentage points), thereby helping to equalize the initial racial/ethnic disparity in utilization. The Passport MMC program in the Louisville-centered region statistically significantly reduced disparities for professional visits (closing the gap by 8.0 percentage points), while the Kentucky Health Select MMC program in the Lexington-centered region did not. No substantive impact on disparities was found for either outpatient or inpatient utilization in either program.Conclusions: We find evidence that MMC has the possibility to reduce racial/ethnic disparities in professional utilization. More work is needed to determine which managed care program characteristics drive this result. [ABSTRACT FROM AUTHOR]

Objective: To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an "early expansion" under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes.Data Sources/study Setting: 2008-2012 American Community Survey (ACS). The sample contained California adults ages 19-64 years (n = 237,876) and children 0-18 years (n = 113,159) with incomes below 200 percent of the federal poverty level.Study Design: Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children.Principal Findings: Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment.Conclusions: California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of the Oregon and New Mexico Health Insurance Flexibility and Accountability (HIFA) demonstrations. HIFA is an optional state Medicaid expansion targeted at adults and children with incomes below 200 percent of the federal poverty level (FPL). The study has five research questions: What type of health insurance do HIFA enrollees self report in surveys? What are the demographic characteristics of these enrollees? What type of health insurance coverage, if any, did HIFA enrollees have just prior to enrollment in the HIFA program? Among those with prior coverage, what prompted participation in the HIFA program? What type of health insurance, if any, would HIFA enrollees have in the absence of HIFA?Methods: Data were collected via telephone interviews with a total of 406 enrollees from Oregon and 409 enrollees from New Mexico. The survey was conducted between July 7 and September 20, 2009, for both states. The sample frame for the survey was based on administrative records of adults enrolled in June 2009. After completion of the survey, active enrollment status as of the date the telephone interview was confirmed. Respondents no longer enrolled at the time of the survey (7 cases in NM and 14 in OR) were excluded from the analysis. The final sample size was 794 verified HIFA enrollees.Results: HIFA enrollees tended to be middle-aged, male, and relatively unhealthy. Employment status varied tremendously from the self-employed to retired to unable to work. HIFA enrollees were reasonably well educated with 80 percent having at least a high school education. Most HIFA enrollees (90 percent) reported being uninsured just prior to participation in HIFA. Of those who were uninsured, most reported having been uninsured for an extended time-a year or more. Most enrollees joined HIFA because they lacked access to health insurance or could not afford insurance on the private market. The overwhelming majority (76 percent) of respondents believed that they would be uninsured in the absence of HIFA, with few considering either an employer plan or private purchase to be a viable option. Over 90 percent of enrollees correctly indicated they had insurance coverage. However, characterization of the type of coverage was problematic, particularly in the absence of the program-specific name.Conclusions: HIFA enrolled a relatively sick, male, middle-aged population that tended to have been long-term uninsured--the kind of enrollees for which the programs were designed--with little apparent crowd-out of private insurance. The reported health status coupled with low incomes suggests that individual purchase is unlikely, a sentiment echoed by the respondents. In the absence of HIFA, most enrollees believed they would rejoin the ranks of the uninsured from where they came. [ABSTRACT FROM AUTHOR]

Objective: Millions of low-income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out-of-pocket spending.Data Sources: Secondary data from the 1998-2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.Study Design: Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out-of-pocket spending for mental health services.Data Extraction Methods: Person-year files were constructed including adults ages 21-64 under 300 percent of the Federal Poverty Level.Principal Findings: Medicaid expansions significantly increased health insurance coverage and reduced out-of-pocket spending on mental health services for low-income adults. Effects of expanded Medicaid eligibility on out-of-pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.Conclusions: Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out-of-pocket mental health care spending. [ABSTRACT FROM AUTHOR]

Objective: Examine measurement error to public health insurance in the American Community Survey (ACS).Data Sources/study Setting: The ACS and the Medicaid Statistical Information System (MSIS).Study Design: We tabulated the two data sources separately and then merged the data and examined health insurance reports among ACS cases known to be enrolled in Medicaid or expansion Children's Health Insurance Program (CHIP) benefits.Data Collection/extraction Methods: The two data sources were merged using protected identification keys. ACS respondents were considered enrolled if they had full benefit Medicaid or expansion CHIP coverage on the date of interview.Principal Findings: On an aggregated basis, the ACS overcounts the MSIS. After merging the data, we estimate a false-negative rate in the 2009 ACS of 21.6 percent. The false-negative rate varies across states, demographic groups, and year. Of known Medicaid and expansion CHIP enrollees, 12.5 percent were coded to some other coverage and 9.1 percent were coded as uninsured.Conclusions: The false-negative rate in the ACS is on par with other federal surveys. However, unlike other surveys, the ACS overcounts the MSIS on an aggregated basis. Future work is needed to disentangle the causes of the ACS overcount. [ABSTRACT FROM AUTHOR]

Objective To assess health care utilization among children enrolled in Medicaid and CHIP via Express Lane Eligibility ( ELE). Data Sources/Study Setting Enrollment, claims, and encounter data for children enrolled in Medicaid or CHIP in Alabama, Iowa, Louisiana, and New Jersey during 2009-2012. Study Design We compared health care utilization among children enrolled via ELE and nondisabled children who enrolled through standard pathways in each state. We used a two-step estimation approach, examining the likelihood of utilization and then the volume and cost of services among users. Regression adjustment corrected for demographic differences. Principal Findings Most ELE and comparison group children used services within a year of enrollment and accessed a variety of services, including outpatient care, prescription drugs, and dental and vision care. ELE enrollees were somewhat less likely to use each service type, and those who used services often did so less intensively compared to other enrollees in their state. Conclusions Health care use patterns suggest that ELE enrollees are aware of their coverage; enrollees accessed and repeatedly used services covered by public health insurance. However, states considering this policy may expect that remaining eligible but uninsured children may be less expensive to cover than existing beneficiaries. [ABSTRACT FROM AUTHOR]

Objective To investigate the determinants and quality of coverage decisions among uninsured choosing plans in a hypothetical health insurance marketplace. Study Setting Two samples of uninsured individuals: one from an Internet-based sample comprised largely of young, healthy, tech-savvy individuals ( n = 276), and the other from low-income, rural Virginians ( n = 161). Study Design We assessed whether health insurance comprehension, numeracy, choice consistency, and the number of plan choices were associated with participants' ability to choose a cost-minimizing plan, given their expected health care needs (defined as choosing a plan costing no more than $500 in excess of the total estimated annual costs of the cheapest plan available). Data Collection Primary data were collected using an online questionnaire. Principal Findings Uninsured who were more numerate showed higher health insurance comprehension; those with more health insurance comprehension made choices of health insurance plans more consistent with their stated preferences; and those who made choices more concordant with their stated preferences were less likely to choose a plan that cost more than $500 in excess of the cheapest plan available. Conclusions Increasing health insurance comprehension and designing exchanges to facilitate plan comparison will be critical to ensuring the success of health insurance marketplaces. [ABSTRACT FROM AUTHOR]

Objective To determine if providing dental insurance to older Americans would close the current gaps in dental use and expenditure between insured and uninsured older Americans. Data Sources/Study Setting We used data from the 2008 Health and Retirement Survey ( HRS) supplemented by data from the 2006 Medical Expenditure Panel Survey ( MEPS). Study Design We compared the simulated dental use and expenditures rates of newly insured persons against the corresponding rates for those previously insured. Data Collection/Extraction Methods The HRS is a nationally representative survey administered by the Institute for Social Research ( ISR). The MEPS is a nationally representative household survey sponsored by the Agency for Healthcare Research and Quality ( AHRQ). Principal Findings We found that expanding dental coverage to older uninsured Americans would close previous gaps in dental use and expense between uninsured and insured noninstitutionalized Americans 55 years and older. Conclusions Providing dental coverage to previously uninsured older adults would produce estimated monthly costs net of markups for administrative costs that comport closely to current market rates. Estimates also suggest that the total cost of providing dental coverage targeted specifically to nonusers of dental care may be less than similar costs for prior users. [ABSTRACT FROM AUTHOR]