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Objective: The Affordable Care Act (ACA) introduced reforms to mitigate adverse selection into and within the individual insurance market. We examined the traits and predicted medical spending of enrollees in California post-ACA.Data Sources: Survey of 2,103 enrollees in individual market plans, on- and off-exchange, in 2014.Study Design: We compared actual versus potential participants using data from the 2014 California Health Interview Survey on respondents who were individually insured or uninsured. We predicted annual medical spending for each group using age, sex, self-rated health, body mass index, smoking status, and income.Principal Findings: Average predicted spending was similar for actual ($3,377, 95 percent CI [$3,280-$3,474]) and potential participants ($3,257 [$3,060-$3,454]); however, some vulnerable subgroups were underrepresented. On- versus off-exchange enrollees differed in sociodemographic and health traits with modest differences in spending ($3,448 [$3,330-$3,565] vs. $3,175 [$3,012-$3,338]).Conclusions: We did not find evidence of selection into the overall insurance pool in 2014; however, differences by exchange status reflect the importance of including off-exchange enrollees in analyses and the pool for risk adjustment. California's post-ACA individual market has been a relative success, highlighting the importance of state policies and outreach efforts to encourage participation in the market. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in children's albuterol use and out-of-pocket (OOP) costs in response to increased copayments after the Food and Drug Administration banned inhalers with chlorofluorocarbon (CFC) propellants.Setting: Four health maintenance organizations (HMOs), two that increased copayments for albuterol inhalers that went from generic CFC-containing to branded CFC-free versions, and two that retained generic copayments for CFC-free inhalers (controls). We included children with asthma aged 4-17 years with commercial coverage from 2007 to 2010.Design: Interrupted time series with comparison series.Data: We obtained enrollee and plan characteristics from enrollment files, and utilization data from pharmacy and medical claims; OOP expenditures were extracted from pharmacy claims for two HMOs with cost data available.Findings: There were no significant differences in albuterol use between the group with increased cost-sharing and controls with respect to changes after the policy change. There was a postpolicy increase of $6.11 OOP per month per child using albuterol among those with increased cost-sharing versus $0.36 in controls; the difference between groups was significant (p < .01).Conclusions: Increased copayments for brand-name CFC-free albuterol after the CFC ban did not lead to a decrease in children's albuterol use, but it led to a modest increase in OOP costs. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses the potential negative effects of not renewing the American Rescue Plan Act, including an increase in out-of-pocket premiums in 2023 and a loss of protections afforded by prior coverage gains. [ABSTRACT FROM AUTHOR]

Food insecurity and poor nutrition are prevalent in the United States and associated with chronic diseases. Understanding relationships among food insecurity, diet, and health care utilization can inform strategies to reduce health disparities. Our aim was to determine associations between food security status and inpatient and outpatient health care utilization and whether they differed by dietary quality in lower-income adults. This was a cross-sectional study of data from the 2009-2016 National Health and Nutrition Examination Survey. Participants were 13,956 lower-income (<300% federal poverty level) adults 18 years and older in the United States. Self-reported health care utilization in the past 12 months included no usual source of care, any outpatient visit, any mental health service use, and any hospitalization. Multiple logistic regression was used to study the association between food insecurity and health care utilization. Analyses were stratified by diet-related comorbidities to account for potential confounding and mediation of health care utilization, and by dietary quality. In a sample of lower-income adults <300% federal poverty level, 4,319 participants (27.4%) were food insecure, 2,208 (15.0%) were marginally food secure, and 7,429 (57.6%) were food secure. Food insecurity was associated with having no usual source of care (adjusted odds ratio [aOR] 1.30; 95% CI 1.11 to 1.52), any mental health service use (aOR 2.02; 95% CI 1.61 to 2.52), and any hospitalization (aOR 1.19; 95% CI 1.01 to 1.41). Food-insecure adults were more likely to report no outpatient visits if they had diet-related comorbidities (aOR 1.45; 95% CI 1.10 to 1.92) or the lowest dietary quality (aOR 1.53; 95% CI 1.06 to 2.23). Marginal food security was associated with having no usual source of care (aOR 1.22; 95% CI 1.04 to 1.44). Adults with food insecurity were more likely to be hospitalized, use mental health services, and have no usual source of care. Food-insecure participants with diet-related comorbidities or poor diet were less likely to have outpatient visits. Hospitalizations and mental health visits represent underused opportunities to identify and address food insecurity and dietary intake in lower-income patients. [ABSTRACT FROM AUTHOR]

Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives. [ABSTRACT FROM AUTHOR]

High deductible—based health insurance plans require consumers to pay for care until reaching the deductible amount. However, information is limited on how well consumers understand their benefits and how they respond to these costs. In telephone interviews, we found that consumers had limited knowledge about their deductibles yet frequently reported changing their care-seeking behavior because of the cost. Poor knowledge limited the effects of the deductible design, with some consumers avoiding care for services that were exempt from the deductible. Consumers need more information and decision support to understand their benefits and to differentiate when care is necessary, discretionary, or unnecessary. [ABSTRACT FROM AUTHOR]

The article presents a study to determine Medicare beneficiaries' knowledge of the benefits and cost responses of the Medicare Advantage Prescription Drug plan in the U.S. The study measured awareness of the coverage gap and cost-coping behaviors such as switching medications, non-adherence and the forgoing of basic needs by the elderly in the U.S. The design, setting and participants of the telephone interview study are defined. Research showed a 40% awareness of a coverage gap in the drug plan by those interviewed, while 30% reported engaging in one of the cost-coping behaviors measured.

This study uses national survey data to assess the prevalence and health-related correlates of housing problems among community health center patients. [ABSTRACT FROM AUTHOR]

Objective To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act ( COBRA) premium subsidy for workers laid off in 2008-2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions. Study Design/Data Collection Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate). Principal Findings Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending. Conclusion Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock. [ABSTRACT FROM AUTHOR]

Introduction: US adults with serious mental illness (SMI), compared to those without SMI, have a higher prevalence of smoking, which contributes to a shorter life expectancy. This study compared current smoking and quitting-related characteristics of low-income US adults with and without SMI who received healthcare at federally funded health centers.Methods: Using cross-sectional data from adults ≥ 18 years old in the nationally representative 2014 Health Center Patient Survey (n = 5592), we compared the prevalence of ever and current smoking among adults with and without SMI and calculated quit ratios as the percentage of ever smokers who have quit smoking. We examined the association between SMI and receiving advice to quit, making quit attempts, and having plans to quit in the next 30 days using multivariable logistic regression.Results: A total of 1376 (23%) of participants had SMI. Ever smoking prevalence was 68% in adults with SMI and 41% in adults without SMI, and current smoking prevalence was 48% and 22%, respectively. The quit ratio was 30% and 46% among participants with and without SMI, respectively. Compared to smokers without SMI, more smokers with SMI reported receiving advice to quit in the past 12 months (aOR 2.47, 95% CI 1.20-5.07). Smokers with and without SMI did not differ significantly in their odds of having made a past-12-month quit attempt or plans to quit.Conclusions: Smokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI. [ABSTRACT FROM AUTHOR]

Objectives: To study the impact of eliminating cost sharing for screening mammography on mammography rates in a large Medicare Advantage (MA) health plan which in 2010 eliminated cost sharing in anticipation of the Affordable Care Act mandate.Study Setting: Large MA health maintenance organization offering individual-subscriber MA insurance and employer-supplemented group MA insurance.Study Design: We investigated the impact on breast cancer screening of a policy that eliminated a $20 copayment for screening mammography in 2010 among 53,188 women continuously enrolled from 2007 to 2012 in an individual-subscriber MA plan, compared with 42,473 women with employer-supplemented group MA insurance in the same health maintenance organization who had full screening coverage during this period. We used differences-in-differences analysis to study the impact of cost-sharing elimination on mammography rates.Principal Findings: Annual screening rates declined over time for both groups, with similar trends pre-2010 and a slower decline after 2010 among women whose copayments were eliminated. Among women aged 65-74 years in the individual-subscriber MA plan, 44.9 percent received screening in 2009 compared with 40.9 percent in 2012, while 49.5 percent of women in the employer-supplemented MA plan received screening in 2009 compared with 44.1 percent in 2012, that is, a difference-in-difference effect of 1.4 percentage points less decline in screening among women experiencing the cost-sharing elimination. Effects were concentrated among women without recent screening. There were no differences by neighborhood socioeconomic status or race/ethnicity.Conclusions: Eliminating cost sharing for screening mammography was associated with modesty lower decline in screening rates among women with previously low screening adherence. [ABSTRACT FROM AUTHOR]

Purpose: In 2009, the US Food and Drug Administration (FDA) mandated a label change for leukotriene inhibitors (LTIs) to include neuropsychiatric adverse events (eg, depression and suicidality) as a precaution. This study investigated how this label change affected the use of LTIs and other asthma controller medications, mental health visits, and suicide attempts. Methods: We analyzed data (2005-2010) from 5 large health plans in the US Population-Based Effectiveness in Asthma and Lung Diseases (PEAL) Network. The study cohort included children and adolescents (n = 30,000), young adults (n = 20,0), and adults (n = 90,000) with asthma. We used interrupted time series to examine changes in rates of LTI dispensings, non-LTI dispensings, mental health visits, and suicide attempts (using a validated algorithm based on a combination of diagnoses of injury or poisoning and psychiatric conditions). Findings: The label change was associated with abrupt reductions in LTI use among all age groups (relative reductions of 8.3%, 15.1%, and 6.0% among adolescents, young adults, and adults, respectively, compared with expected rates at 1 year after the warnings). Although we detected immediate offset increases in non-LTI asthma medication use, these increases were not sustained among adolescents and young adults. There were small increases in mental health visits among LTI users. Implications: The FDA label change for LTIs communicated possible risk of neuropsychiatric events. Communication and enhanced awareness may have increased reporting of mental health symptoms among young adults and adults. It is important to assess intended and unintended consequences of FDA warnings and label changes. [ABSTRACT FROM AUTHOR]

Background: Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries. Methods: We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at $1,000 and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements. Results: After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, −4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more. Conclusions: A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care. N Engl J Med 2006;354:2349-59. [ABSTRACT FROM AUTHOR]