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In 2021 the American Rescue Plan Act increased premium subsidies for people purchasing insurance from the Affordable Care Act Marketplaces and provided zero-premium Marketplace plans that covered 94 percent of medical care costs (silver 94 plans) to recipients of unemployment compensation. Using data on adult enrollees in on- and off-Marketplace individual plans in California in 2021, we found that 41 percent reported incomes at or below 400 percent of the federal poverty level and that 39 percent reported living in households receiving unemployment compensation. Overall, 72 percent of enrollees reported having no difficulty paying premiums, and 76 percent reported that out-of-pocket expenses did not affect their seeking of medical care. The majority of enrollees eligible for plans with cost-sharing subsidies were enrolled in Marketplace silver plans (56-58 percent). Many of these enrollees, however, may have missed opportunities for premium or cost-sharing subsidies: 6-8 percent enrolled in off-Marketplace plans and were more likely to have difficulty paying premiums than those in Marketplace silver plans, and more than one-quarter enrolled in Marketplace bronze plans and were more likely to delay care because of cost than those in Marketplace silver plans. In the coming era of expanded Marketplace subsidies under the Inflation Reduction Act of 2022, helping consumers identify high-value and subsidy-eligible plans could mitigate remaining affordability problems.

The tax penalty for noncompliance with the Affordable Care Act's individual mandate is to be eliminated starting in 2019. We investigated the potential impact of this change on enrollees' decisions to purchase insurance and on individual-market premiums. In a survey of enrollees in the individual market in California in 2017, 19 percent reported that they would not have purchased insurance had there been no penalty. We estimated that premiums would increase by 4-7 percent if these enrollees were not in the risk pool. The percentages of enrollees who would forgo insurance were higher among those with lower income and education, Hispanics, and those who had been uninsured in the prior year, relative to the comparison groups. Compared to older enrollees and those with two or more chronic conditions, respectively, younger enrollees and those with no chronic conditions were also more likely to say that they would not have purchased insurance. Eliminating the mandate penalty alone is unlikely to destabilize the California individual market but could erode coverage gains, especially among groups whose members have historically been less likely to be insured.

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., (© Health Research and Educational Trust.)

Objective: There is limited information on the protective value of Medicare Part D low-income subsidies (LIS). We compared responses to drug costs for LIS recipients with near-poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS., Data Sources/study Setting: Medicare Advantage beneficiaries in 2008., Study Design: We examined three drug cost responses using multivariate logistic regression: cost-reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities)., Data Collection: Telephone interviews in a stratified random sample (N = 1,201, 70 percent response rate)., Principal Findings: After adjustment, a comparable percentage of unsubsidized near-poor (26 percent) and higher income beneficiaries reported cost-reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost-reducing behaviors (15 percent, p = .019 vs near-poor). Unsubsidized near-poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near-poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015)., Conclusions: Low-income subsidies provide protection from drug cost-related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors., (© Health Research and Educational Trust.)

Background: Variance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (or intraclass correlation, ICC) in a quality measure; low ICCs have been interpreted to indicate low potential for quality improvement at that level. However, the absolute amount of variation, expressed in clinically meaningful units, is less frequently reported. Moreover, changes in variance components have not been studied as quality improves., Objectives: To examine changes in variance components at primary care physician and medical facility levels as performance improved for 4 quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates., Population: Adult members (n = 62,596-410,976) of Kaiser Permanente in Northern California, served by more than 1000 primary care physicians in 35 facilities, from 2001 to 2006., Methods: Multilevel linear and logistic regression to examine the interphysician and interfacility variances in 4 quality indicators over 6 years, after case-mix adjustment., Results: ICCs were low for all 4 indicators at both levels (0.0021-0.086). Nevertheless, variances at both levels were statistically and clinically significant. For systolic blood pressure and the care experience score, interfacility and interphysician variance as well as ICCs decreased further as quality improved; declines were greater at the facility level. For low-density lipoprotein-cholesterol, variability at both levels increased with quality improvement; and for screening mammography, small declines were not statistically significant for either physicians or facilities., Conclusions: Low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all 4 indicators.

Objective: To examine drug costs and entry and exit rates into the Part D coverage gap for beneficiaries with diabetes in Medicare Advantage managed care plans., Study Design: Cross-sectional observational study., Methods: Study patients were Medicare Advantage Part D beneficiaries with diabetes from 2 large California health plans who were continuously enrolled in 2006 and had a drug coverage gap starting at $2250. Entry and exit into the gap, total drug costs, and out-of-pocket drug costs were determined using pharmacy databases., Results: In 2006, 26% of the 42,801 beneficiaries with diabetes reached the coverage gap; 2% of beneficiaries exited the gap and qualified for catastrophic coverage. Beneficiaries incurred a mean of $2182 in total drug costs during 2006. Drug expenditures remained stable over the year for beneficiaries who did not enter the gap. For beneficiaries who entered the gap, total drug costs were higher overall and decreased at year's end as out-of-pocket expenses increased., Conclusions: Fewer diabetes patients in this study entered the coverage gap than had been previously estimated, but the entry rate was much higher than that of the general Medicare Advantage Part D population. Patients entering the gap had lower subsequent monthly drug expenditures; this may be due to lower-than-expected drug prices and greater use of generics in managed care, or it may potentially signal poorer drug adherence. Future work should examine these hypotheses and explore risk factors for entering the Part D coverage gap.

Context: Medicare Part D drug benefits include substantial cost sharing., Objective: To determine beneficiaries' knowledge of benefits and cost responses., Design, Setting, and Participants: Telephone interviews were conducted in 2007 in a stratified random sample of community-dwelling Kaiser Permanente-Northern California Medicare Advantage beneficiaries aged 65 years or older, with a gap in coverage if they exceeded $2250 in drug costs (N = 1040; 74.9% response rate). Half were selected to have reached the gap in 2006. In the source population of Medicare Advantage Prescription Drug plan beneficiaries, 8% entered the coverage gap in 2006. Models were adjusted for individual characteristics and weighted for sampling proportions., Main Outcome Measures: Knowledge of cost sharing including awareness of the coverage gap, gap start and end amounts, and drug cost sharing before, during, and after the gap. Cost-related responses including cost-coping behaviors (eg, switching to lower-cost medications), reduced adherence (eg, not refilling prescriptions), and financial burden (eg, going without necessities)., Results: An estimated 40% (95% confidence interval [CI], 35%-45%) of beneficiaries were aware that their drug plan in 2006 included a coverage gap; knowledge of the gap was greater among individuals who reached the gap during the year. Approximately 36% (95% CI, 32%-41%) of beneficiaries reported at least 1 of the following responses to drug costs: cost-coping behavior (26%), reduced adherence (15%), or experiencing financial burden (7%). In multivariate analyses, beneficiaries with lower household income more frequently reported cost responses (difference of 14.5 percentage points for < $40,000/y vs > or = $40,000/y [95% CI, 3.6-25.4 percentage points]). Compared with beneficiaries who were unaware of having a coverage gap, those who were aware more frequently reported any cost response (difference of 11.3 percentage points [95% CI, 0.8-21.9 percentage points]), but had fewer reports of borrowing money or going without necessities (difference of 5.5 percentage points [95% CI, 1.1-10.0 percentage points])., Conclusions: Beneficiaries in this Medicare Advantage plan have limited knowledge of Part D cost sharing and often report behavioral responses to drug costs. Limited knowledge is associated with fewer reports of cost responses overall, but more reports of financial burden.

Background: E-health services may improve the quality and efficiency of care; however, there is little quantitative data on e-health use., Objective: The objective of this study was to examine trends in e-health use and user characteristics., Research Design: This was a longitudinal study of e-health use (1999-2002) within an integrated delivery system (IDS). We classified 4 e-health services into transactional (drug refills and appointment scheduling) and care-related (medical and medication advice) services., Subjects: Approximately 3.3 million members of a large, prepaid IDS., Measurements: Amount and frequency of e-health use over time and characteristics of users., Results: The number of members registered for access to e-health increased from 20,617 (0.7% of all members) in Q1 1999 to 270,987 (8.6%) in Q3 2002. Between Q1 and Q3 2002, 42,845 members (1.3%) used the drug refill service and 55,901 (1.7%) used the appointment scheduling service compared with 10,756 members (0.3%) who used the medical advice service and 3069 (0.1%) who used the medication advice service. Over the same period, transactional service users averaged 3.5 uses/user versus 1.6 uses/user among care-related service users. Members most likely to use e-health services had a high level of clinical need, a regular primary care provider, were 30 to 64 years old, female, white, and lived in a nonlow socioeconomic status neighborhood. These findings were consistent across e-health service types., Conclusions: Although use of all e-health services grew rapidly, use of care-related services lagged significantly behind use of transactional services. Subjects with greater clinical need and better ties to the health system were more likely to use both types of e-health services.