Sharing the caring
Improving The Affordable Care Act: An Assessment Of Policy Options For Providing Subsidies
Evan Saltzman, Christine Eibner & Alain Enthoven
Health Affairs, December 2015, Pages 2095-2103
Abstract:
A key challenge of health reform efforts is to make health insurance affordable for individuals and families who lack coverage without harming those with coverage or increasing federal spending. The Affordable Care Act (ACA) addresses this challenge in part by providing tax subsidies to qualified individuals for purchasing individual insurance and retaining tax exemptions for employer and employee contributions to the cost of premiums of employer-sponsored insurance. These tax exemptions cost approximately $250 billion annually in lost tax revenue and have been criticized for favoring higher earners and conferring preferential treatment of employer-sponsored over individual insurance. We analyzed three options for leveling the financial playing field between the two insurance markets by reallocating the value of tax benefits of employer coverage. We found that one option that uses the subsidy formula employed in the insurance Marketplaces under the ACA for both the individual and employer-sponsored insurance markets, and additionally requires the subsidy to be at least $1,250 without an upper income limit on subsidy eligibility imposed, could expand insurance coverage and reduce individual market premiums relative to the ACA with no additional federal spending.
---------------------
Internalizing Behavioral Externalities: Benefit Integration in Health Insurance
Amanda Starc & Robert Town
NBER Working Paper, December 2015
Abstract:
We show that profit-maximizing firms alter product design in the market for Medicare prescription drug coverage to account for underutilization by consumers. Using plausibly exogenous variation in coverage, we examine prescription drug utilization under two different plan structures. We document that plans that cover all medical expenses spend more on drugs than plans that are only responsible for prescription drug spending, consistent with drug spending offsetting some medical costs. The effect is driven by drugs that are likely to generate substantial offsets. Our supply side model confirms that differential incentives across plans can explain this disparity. Counterfactuals show that the externality created by stand-alone drug plans is $405 million per year. Finally, we explore the extent to which subsidies and information provision can mitigate the externality generated by under-consumption.
---------------------
Medicaid Expansion Did Not Result In Significant Employment Changes Or Job Reductions In 2014
Angshuman Gooptu et al.
Health Affairs, January 2016, Pages 111-118
Abstract:
Medicaid expansion undertaken through the Affordable Care Act (ACA) is already producing major changes in insurance coverage and access to care, but its potential impacts on the labor market are also important policy considerations. Economic theory suggests that receipt of Medicaid might benefit workers who would no longer be tied to specific jobs to receive health insurance (known as job lock), giving them more flexibility in their choice of employment, or might encourage low-income workers to reduce their hours or stop working if they no longer need employment-based insurance. Evidence on labor changes after previous Medicaid expansions is mixed. To view the impact of the ACA on current labor market participation, we analyzed labor-market participation among adults with incomes below 138 percent of the federal poverty level, comparing Medicaid expansion and nonexpansion states and Medicaid-eligible and -ineligible groups, for the pre-ACA period (2005-13) and the first fifteen months of the expansion (January 2014-March 2015). Medicaid expansion did not result in significant changes in employment, job switching, or full- versus part-time status. While we cannot exclude the possibility of small changes in these outcomes, our findings rule out the large change found in one influential pre-ACA study; furthermore, they suggest that the Medicaid expansion has had limited impact on labor-market outcomes thus far.
---------------------
Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply
Robert Kaestner et al.
NBER Working Paper, December 2015
Abstract:
We examined the effect of the expansion of Medicaid eligibility under the Affordable Care Act on health insurance coverage and labor supply of adults with a high school education or less. We found that the Medicaid expansions increased Medicaid coverage by approximately 4 percentage points, decreased the proportion uninsured by approximately 3 percentage points, and decreased private health insurance coverage by 1 percentage point. The Medicaid expansions had little effect on labor supply as measured by employment, usual hours worked per week and the probability of working 30 or more hours per week. Most estimates suggested that the expansions increased employment slightly, although not significantly.
---------------------
Little Change Seen In Part-Time Employment As A Result Of The Affordable Care Act
Asako Moriya, Thomas Selden & Kosali Simon
Health Affairs, January 2016, Pages 119-123
Abstract:
There has been speculation that the Affordable Care Act's coverage provisions and employer mandate have led to an increase in part-time employment. Using the Current Population Survey for the period 2005-15, we examined data on weekly hours worked by firm size, reason for working part time, age, education, and health insurance. We found only limited evidence to support this speculation.
---------------------
The Growing Difference Between Public And Private Payment Rates For Inpatient Hospital Care
Thomas Selden et al.
Health Affairs, December 2015, Pages 2147-2150
Abstract:
The difference between private and public (Medicare and Medicaid) payment rates for inpatient hospital stays widened between 1996 and 2012. Medical Expenditure Panel Survey data reveal that standardized private insurer payment rates in 2012 were approximately 75 percent greater than Medicare's - a sharp increase from the differential of approximately 10 percent in the period 1996-2001.
---------------------
The Marginal Benefit of Inpatient Hospital Treatment: Evidence from Hospital Entries and Exits
Nathan Petek
University of Chicago Working Paper, December 2015
Abstract:
The marginal benefit of health care determines the extent to which policies that change health care consumption affect health. I use variation in access to hospitals caused by nearly 1,300 hospital entries and exits to estimate the marginal benefit of inpatient care. I show that hospital entries and exits cause sharp changes in the quantity of inpatient care, but there is no evidence of an effect on average mortality with tight confidence intervals. I find suggestive evidence of an effect on mortality in rural areas and for the over-65 population with magnitudes that imply the marginal benefit of inpatient care is significantly higher for these populations than for the average patient.
---------------------
Quantifying Gains in the War on Cancer Due to Improved Treatment and Earlier Detection
Seth Seabury et al.
Forum for Health Economics and Policy, forthcoming
Introduction: There have been significant improvements in both treatment and screening efforts for many types of cancer over the past decade. However, the effect of these advancements on the survival of cancer patients is unknown, and many question the value of both new treatments and screening efforts.
Methods: This study uses a retrospective analysis of SEER Registry data to quantify reductions in mortality rates for cancer patients diagnosed between 1997 and 2007. Using variation in trends in mortality rates by stage of diagnosis across cancer types, we use logistic regression to decompose separate survival gains into those attributable to advances in treatment versus advances in detection. We estimate the gains in survival due to gains in both treatment and detection overall and separately for 15 of the most common cancer types.
Results: We estimate that 3-year cancer-related mortality of cancer patients fell 16.7% from 1997 to 2007. Overall, advances in treatment reduced mortality rates by approximately 12.2% while advances in early detection reduced mortality rates by 4.5%. The relative importance of treatment and detection varied across cancer types. Improvements in detection were most important for thyroid, prostate and kidney cancer. Improvements in treatment were most important for non-Hodgkins lymphoma, lung cancer and myeloma.
Conclusion: Both improved treatment options and better early detection have led to significant survival gains for cancer patients diagnosed from 1997 to 2007, generating considerable social value over this time period.
---------------------
Leah Honigman Warner et al.
Health Affairs, December 2015, Pages 2151-2159
Abstract:
Emergency department (ED) crowding adversely affects patient care and outcomes. Despite national recommendations to address crowding, it persists in most US EDs today. Using nationally representative data, we evaluated the use of interventions to address crowding in US hospitals in the period 2007-10. We examined the relationship between crowding within an ED itself, measured as longer ED lengths-of-stay, and the number of interventions adopted. In our study period the average number of interventions adopted increased from 5.2 to 6.6, and seven of the seventeen studied interventions saw a significant increase in adoption. In general, more crowded EDs adopted greater numbers of interventions than less crowded EDs. However, in the most crowded quartile of EDs, a large proportion had not adopted effective interventions: 19 percent did not use bedside registration, and 94 percent did not use surgical schedule smoothing. Thus, while adoption of strategies to reduce ED crowding is increasing, many of the nation's most crowded EDs have not adopted proven interventions.
---------------------
Melissa Boyle & Joanna Lahey
Journal of Health Economics, January 2016, Pages 63-76
Abstract:
Measuring the total impact of health insurance receipt on household labor supply is important in an era of increased access to publicly-provided and subsidized insurance. Although government expansion of health insurance to older workers leads to direct labor supply reductions for recipients, there may be spillover effects on the labor supply of uncovered spouses. While the most basic model predicts a decrease in overall household work hours, financial incentives such as credit constraints, target income levels, and the need for own health insurance suggest that spousal labor supply might increase. In contrast, complementarities of spousal leisure would predict a decrease in labor supply for both spouses. Utilizing a mid-1990s expansion of health insurance for U.S. veterans, we provide evidence on the effects of public insurance availability on the labor supply of spouses. Using data from the Current Population Survey and Health and Retirement Study, we employ a difference-in-differences strategy to compare the labor market behavior of the wives of older male veterans and non-veterans before and after the VA health benefits expansion. Although husbands' labor supply decreases, wives' labor supply increases, suggesting that financial incentives dominate complementarities of spousal leisure. This effect is strongest for wives with lower education levels and lower levels of household wealth and those who were not previously employed full-time. These findings have implications for government programs such as Medicare and Social Security and the Affordable Care Act.
---------------------
Jennifer Perloff, Catherine DesRoches & Peter Buerhaus Health Services Research, forthcoming
Objective: This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs).
Data Source: Medicare Part A (inpatient) and Part B (office visit) claims for 2009-2010.
Principal Findings: After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well.
Conclusions: This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.
---------------------
Benjamin Sommers, Robert Blendon & John Orav
Health Affairs, January 2016, Pages 96-105
Abstract:
Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the "private option"). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November-December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky's traditional Medicaid expansion and Arkansas's private option, which suggests that both approaches improved access among low-income adults.
---------------------
Matthew McHugh et al.
Medical Care, January 2016, Pages 74-80
Background: Although nurses are the most likely first responders to witness an in-hospital cardiac arrest (IHCA) and provide treatment, little research has been undertaken to determine what features of nursing are related to cardiac arrest outcomes.
Research Design: Cross-sectional study of data from: (1) the American Heart Association's Get With The Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and and Patient Safety; and (3) the American Hospital Association annual survey. Logistic regression models were used to determine the association of the features of nursing and IHCA survival to discharge after adjusting for hospital and patient characteristics.
Subjects: A total of 11,160 adult patients aged 18 and older between 2005 and 2007 in 75 hospitals in 4 states (Pennsylvania, Florida, California, and New Jersey).
Results: Each additional patient per nurse on medical-surgical units was associated with a 5% lower likelihood of surviving IHCA to discharge (odds ratio=0.95; 95% confidence interval, 0.91-0.99). Further, patients cared for in hospitals with poor work environments had a 16% lower likelihood of IHCA survival (odds ratio=0.84; 95% confidence interval, 0.71-0.99) than patients cared for in hospitals with better work environments.
Conclusions: Better work environments and decreased patient-to-nurse ratios on medical-surgical units are associated with higher odds of patient survival after an IHCA. These results add to a large body of literature suggesting that outcomes are better when nurses have a more reasonable workload and work in good hospital work environments. Improving nurse working conditions holds promise for improving survival following IHCA.
---------------------
Fred Hellinger
Health Affairs, December 2015, Pages 2061-2068
Abstract:
This study examines the influence of the Affordable Care Act's optional state Medicaid expansion on insurance coverage and health outcomes for hospitalized patients with HIV. I used data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for all hospitalizations of patients with HIV from 2012 through the first six months of 2014 in four states that expanded their Medicaid programs and two states that did not. I found that the percentage of hospitalizations of uninsured people with HIV in the four expansion states fell from 13.7 percent to 5.5 percent in the study period, while the percentage in the two nonexpanding states increased from 14.5 percent to 15.7 percent. I also found that hospitalized patients with HIV who did not have insurance were 40 percent more likely to die during their hospital stays than comparable patients with insurance.
---------------------
Gloria Bazzoli
Health Services Research, forthcoming
Objective: To assess the effects on hospitals of early California actions to expand insurance coverage for low-income uninsured adults after passage of the Affordable Care Act.
Data Sources/Study Setting: Data from the California Office of Statewide Health Planning and Development and the California Department of Health were merged with U.S. census data for 294 short-term general hospitals during the period 2009-2012.
Study Design: A difference-in-difference analysis was conducted with hospitals in counties that did not implement insurance expansions used as a comparison group. Variables examined included payer mix, costs of unreimbursed care, and hospital operating margin. Sensitivity analyses were conducted as well as a triple difference analysis. Effects were estimated for hospitals overall and by ownership type.
Principal Findings: California insurance expansions primarily benefited for-profit hospitals, with these facilities experiencing significant decreases in self-pay patients, increases in county-covered patients, and reductions in charity care. Most models yielded no significant change in payer mix and conflicting changes in unreimbursed care for nonprofit hospitals.
Conclusions: California hospitals that treated the most uninsured prior to insurance expansions did not as a group experience substantial benefit in terms of reduced uninsured burden or better financial performance after program expansions occurred.
---------------------
Insurer Competition In Federally Run Marketplaces Is Associated With Lower Premiums
Paul Jacobs1, Jessica Banthin & Samuel Trachtman
Health Affairs, December 2015, Pages 2027-2035
Abstract:
Federal subsidies for health insurance premiums sold through the Marketplaces are tied to the cost of the benchmark plan, the second-lowest-cost silver plan. According to economic theory, the presence of more competitors should lead to lower premiums, implying smaller federal outlays for premium subsidies. The long-term impact of the Affordable Care Act on government spending will depend on the cost of these premium subsidies over time, with insurer participation and the level of competition likely to influence those costs. We studied insurer participation and premiums during the first two years of the Marketplaces. We found that the addition of a single insurer in a county was associated with a 1.2 percent lower premium for the average silver plan and a 3.5 percent lower premium for the benchmark plan in the federally run Marketplaces. We found that the effect of insurer entry was muted after two or three additional entrants. These findings suggest that increased insurer participation in the federally run Marketplaces reduces federal payments for premium subsidies.
---------------------
The Effect of Health Reform on Retirement
Helen Levy, Thomas Buchmueller & Sayeh Nikpay
University of Michigan Working Paper, September 2015
Abstract:
Many studies have shown that the availability of health insurance is an important determinant of the retirement decision. Beginning in January 2014, the Affordable Care Act (ACA) made affordable alternatives to employer-sponsored health insurance much more widely available than they had been previously through the establishment of health insurance exchanges and, in some states, the expansion of Medicaid eligibility to low-income, childless adults. We analyze whether these new health insurance options led to an increase in retirement or part-time work among individuals ages 55 through 64 during the first 18 months after the policy took effect. Using data from the basic monthly Current Population Survey from January 2005 through June 2015, we find that there was no increase in retirement in 2014 either overall or in Medicaid expansion states relative to nonexpansion states. We also find no change in the fraction of older workers who are working part-time.
---------------------
Is Death "The Great Equalizer"? The Social Stratification of Death Quality in the United States
Deborah Carr
ANNALS of the American Academy of Political and Social Science, January 2016, Pages 331-354
Abstract:
Socioeconomic status (SES) gradients in mortality risk are well documented, although less is known about whether the quality of older adults' dying experiences is stratified by SES. I focus on six core components of a "good death": pain and symptom management, acceptance, medical care that is concordant with one's preferences, dying at home, emotional preparation, and formal preparations for end-of-life care. Analyses are based on four data sets spanning the 1980s through 2010s, a period marked by rising economic inequalities: Changing Lives of Older Couples (1986-1994), Wisconsin Longitudinal Study (1993-2010), New Jersey End of Life study (2005-2007), and Wisconsin Study of Families and Loss (2010-2014). I find evidence of SES disparities in two outcomes only: pain and advance care planning (ACP), widely considered an important step toward a "good death." Implications for health care policy and practice, against the backdrop of the Affordable Care Act implementation, are discussed.
---------------------
Hospital Quality and Patient Choice: An Empirical Analysis of Mitral Valve Surgery
Guihua Wang et al.
University of Michigan Working Paper, October 2015
Abstract:
Among the myriad of decisions involved in health care delivery, none are more important to medical outcomes than the interrelated choices by individual patients regarding treatment type and service provider. Because such choices are often complex and difficult, it is not surprising that many patients make sub-optimal decisions that lead to compromises in quality of life. We document a wide quality gap among thirty-five hospitals in New York State that perform mitral valve surgery, using distance based instruments to correct for potential selection bias in care allocation. We find that only 40% of New York patients choose to go to one of the six hospitals with quality superior to the state average. We define these six hospitals as Centers of Excellence (CoEs). If all patients from 2009-2012 had gone to the nearest CoE for their procedure, about 343 additional patients would have had their mitral valves repaired. This would have added 785 years of life expectancy and saved $4,593 in per patient lifetime care costs, in exchange for travelling an average of 10.9 miles further to get to a CoE. We find that the major barriers preventing patients from choosing the best quality care are: lack of information, travel cost and payer restrictions. We evaluate polices for removing these barriers to enable informed patient choice.
---------------------
The Effect of Publicized Quality Information on Home Health Agency Choice
Jeah Kyoungrae Jung et al.
Medical Care Research and Review, forthcoming
Abstract:
We examine consumers' use of publicized quality information in Medicare home health care markets, where consumer cost sharing and travel costs are absent. We report two findings. First, agencies with high quality scores are more likely to be preferred by consumers after the introduction of a public reporting program than before. Second, consumers' use of publicized quality information differs by patient group. Community-based patients have slightly larger responses to public reporting than hospital-discharged patients. Patients with functional limitations at the start of their care, at least among hospital-discharged patients, have a larger response to the reported functional outcome measure than those without functional limitations. In all cases of significant marginal effects, magnitudes are small. We conclude that the current public reporting approach is unlikely to have critical impacts on home health agency choice. Identifying and releasing quality information that is meaningful to consumers may help increase consumers' use of public reports.
---------------------
Health information technology and patient outcomes: The role of information and labor coordination
Jeffrey McCullough, Stephen Parente & Robert Town
RAND Journal of Economics, Spring 2016, Pages 207-236
Abstract:
Health information technology (IT) adoption, it is argued, will dramatically improve patient care. We study the impact of hospital IT adoption on patient outcomes focusing on the role of patient and organizational heterogeneity. We link detailed hospital discharge data on all Medicare fee-for-service admissions from 2002-2007 to detailed hospital-level IT adoption information. For all IT-sensitive conditions, we find that health IT adoption reduces mortality for the most complex patients but does not affect outcomes for the median patient. Benefits from health IT are primarily experienced by patients whose diagnoses require cross-specialty care coordination and extensive clinical information management.
---------------------
A Mixed-Methods Study of Patient-Provider E-Mail Content in a Safety-Net Setting
Jacob Mirsky et al.
Journal of Health Communication, January 2016, Pages 85-91
Abstract:
To explore the content of patient-provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.