Sustainable Care

Kevin Lewis

January 23, 2023

Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?Katherine Baicker, Amitabh Chandra & Mark Shepard
NBER Working Paper, January 2023


The United States spends substantially more on health care than most developed countries, yet leaves a greater share of the population uninsured. We suggest that incremental insurance expansions focused on addressing market failures will propagate inefficiencies and are not likely to facilitate active policy decisions that align with societal coverage goals. By instead defining a basic bundle of services that is publicly financed for all, while allowing individuals to purchase additional coverage, policymakers could both expand coverage and maintain incentives for innovation, fostering universal access to innovative care in an affordable system.

Revisiting the Connection Between State Medicaid Expansions and Adult Mortality
Charles Courtemanche et al.
NBER Working Paper, January 2023 


This paper examines the impact of Medicaid expansions to parents and childless adults on adult mortality. Specifically, we evaluate the long-run effects of eight state Medicaid expansions from 1994 through 2005 on all-cause, healthcare-amenable, non-healthcare-amenable, and HIV-related mortality rates using state-level data. We utilize the synthetic control method to estimate effects for each treated state separately and the generalized synthetic control method to estimate average effects across all treated states. Using a 5% significance level, we find no evidence that Medicaid expansions affect any of the outcomes in any of the treated states or all of them combined. Moreover, there is no clear pattern in the signs of the estimated treatment effects. These findings imply that evidence that pre-ACA Medicaid expansions to adults saved lives is not as clear as previously suggested.

Trends In Treat-And-Release Emergency Care Visits With High-Intensity Billing In The US, 2006–19
Alexander Janke et al.
Health Affairs, December 2022, Pages 1772-1780 


Clinicians’ billing practices for professional services in the emergency department (ED) have come under scrutiny as the proportion of expensive high-intensity visits has grown in recent decades. Clinicians respond to payers’ criticism by citing the worsening health status of undifferentiated patients alongside increasing expectations of ED care, with few data available to disentangle these phenomena from coding practices. We performed an observational study of US treat-and-release ED visits using data from the Nationwide Emergency Department Sample. In 2006, 4.8 percent of treat-and-release ED visits exhibited high-intensity billing, and this figure rose to 19.2 percent by 2019. The proportion of visits for older patients, those with more comorbidities, and those with nonspecific but potentially serious diagnoses grew. Of the observed growth in high-intensity billing, 47 percent was expected, based on changes in administrative measures for patient case-mix and care services. Any emergency care reimbursement reform must

 Reducing Ordeals through Automatic Enrollment: Evidence from a Health Insurance Exchange 
Mark Shepard & Myles Wagner
NBER Working Paper, December 2022


Incomplete health insurance enrollment is a persistent U.S. challenge despite large subsidies. We ask whether hassles built into enrollment systems matter for insurance take-up and targeting. Studying removal of an auto-enrollment policy, we find that a small hassle -- a requirement to actively select a health plan to enroll -- reduces take-up by 33%, a major impact equivalent to $470 (57%) higher enrollee premiums. Hassles differentially screen out younger, healthier, and poorer people – groups with both low value and costs of insurance. We show that this value-cost correlation -- a standard feature of insurance, where risk drives both -- may undermine the classic rationale for ordeals' favorable targeting.

Racial Concordance and the Quality of Medical Care: Evidence from the Military
Michael Frakes & Jonathan Gruber
NBER Working Paper, December 2022 


One explanation for insufficient use of primary care in the U.S. is a lack of trust between patients and providers -- particularly along racial lines. We assess the role of racial concordance between patients and medical providers in driving use of preventive care and the implications for patient outcomes. We use unique data from the Military Health System, where we observe providers as patients so that we can identify their race, and where moves across bases change exposure to provider race. We consider patients with four chronic, deadly, but ultimately manageable illnesses, where the relationship with the provider may have the most direct and important impact on health. We find striking evidence that racial concordance leads to improved maintenance of preventive care -- and ultimately lower patient mortality. Pooling across these diseases, we estimate that a one-standard deviation increase in the share of providers who are Black leads to a 15% relative decline in Black mortality among those with these manageable illnesses. Our results further suggest that between 55 and 69% of this mortality impact arises through improved medication use and adherence, with other aspects of the provider-patient relationship accounting for the residual.

Racial And Ethnic Disparities In Preventable Hospitalizations And ED Visits Five Years After ACA Medicaid Expansions
Asako Moriya & Sujoy Chakravarty
Health Affairs, January 2023, Pages 26-34 


Medicaid expansions under the Affordable Care Act (ACA) dramatically increased access to insurance coverage. We examined whether the 2014 ACA Medicaid expansions also mitigated existing racial or ethnic disparities in preventable hospitalizations and emergency department (ED) visits. Using inpatient data from twenty-nine states and ED data from twenty-six states for the period 2011–18, we found that Medicaid expansions decreased disparities in preventable hospitalizations and ED visits between non-Hispanic Black and White nonelderly adults by 10 percent or more. There were no significant effects on disparities between Hispanic and non-Hispanic White nonelderly adults, possibly reflecting lower baseline differences and, separately, persisting coverage disparities. These findings highlight sustained improvements in community-level care for non-Hispanic Black populations, who historically lack access to care. Our findings also suggest access barriers experienced by Hispanic adults that need to be addressed beyond Medicaid eligibility expansion.

Medicaid Expansion Led To Reductions In Postpartum Hospitalizations
Maria Steenland & Laura Wherry
Health Affairs, January 2023, Pages 18-25


The Affordable Care Act (ACA) Medicaid expansions increased preconception and postpartum insurance coverage among low-income birthing people, leading to greater use of outpatient care. In this study we evaluated whether the expansions affected rates of postpartum hospitalization. Our analyses took advantage of underused longitudinal hospital data from the period 2010–17 to examine hospitalizations after childbirth. We compared changes in hospitalizations among birthing people with a Medicaid-financed delivery in states that did and did not expand Medicaid under the ACA. We found a 17 percent reduction in hospitalizations during the first sixty days postpartum associated with the Medicaid expansions and some evidence of a smaller decrease in hospitalizations between sixty-one days and six months postpartum. Our findings indicate that expanding Medicaid coverage led to improved postpartum health for low-income birthing people.

Association of Youth Suicides and County-Level Mental Health Professional Shortage Areas in the US
Jennifer Hoffmann et al.
JAMA Pediatrics, January 2023, Pages 71-80 

Main Outcomes and Measures: Suicides by youth aged 5 to 19 years from 2015 to 2016 were identified from the US Centers for Disease Control and Prevention’s Compressed Mortality File. A multivariable negative binomial regression model was used to analyze the association between youth suicide rates and mental health workforce shortage designation, adjusting for the presence of a children’s mental health hospital and county-level markers of health insurance coverage, education, unemployment, income, poverty, urbanicity, racial and ethnic composition, and year. Similar models were performed for the subgroups of (1) firearm suicides and (2) counties assigned a numeric shortage score.

Results: During the study period, there were 5034 youth suicides (72.8% male and 68.2% non-Hispanic White) with an annual suicide rate of 3.99 per 100 000 youths. Of 3133 US counties, 2117 (67.6%) were designated as mental health workforce shortage areas. After adjusting for county characteristics, mental health workforce shortage designation was associated with an increased youth suicide rate (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.07-1.26) and an increased youth firearm suicide rate (aIRR, 1.27; 95% CI, 1.13-1.42). For counties with an assigned numeric workforce shortage score, the adjusted youth suicide rate increased 4% for every 1-point increase in the score (aIRR, 1.04; 95% CI, 1.02-1.06).

Analysis of Over 2,200 Life Science Companies Reveals a Network of Potentially Illegal Interlocked Boards
Mark Lemley et al.
Stanford Working Paper, October 2022 


Competition between life science companies is critical to ensure innovative therapies are efficiently developed to improve human health. Anticompetitive behavior may harm scientific progress and, ultimately, patients. One well-established category of anticompetitive behavior is the “interlocking directorate.” It is illegal for companies’ directors to “interlock” by also serving on the boards of competitors. To investigate anticompetitive behavior in the life sciences, we evaluated overlaps in the board membership of 2,241 public life science companies since 2000. At any given time, 10-20% of board members are interlocked; their tenures are 50% longer than non-interlocked directors. The number of interlocks has more than doubled in the last two decades. Interlocking directorates are particularly prevalent in oncology, neurology, immunology, and respiratory disease. Over half of all companies with more than $5 million in revenue are interlocked. A significant fraction of the life sciences industry is engaged in anticompetitive—and potentially illegal—behavior.

The Contribution of Price Growth to Pharmaceutical Revenue Growth in the United States: Evidence from Medicines Sold in Retail Pharmacies
Pragya Kakani, Michael Chernew & Amitabh Chandra
Journal of Health Politics, Policy and Law, December 2022, Pages 629–648 

Methods: This study uses data from SSR Health LLC to address these research questions using decomposition methods that analyze list prices, prices net of rebates, and sales for branded pharmaceutical products sold primarily through retail pharmacies.

Findings: From 2009 to 2019, retail pharmaceutical revenue growth was primarily driven by new products rather than by price increases on existing products. Failing to account for confidential rebates creates a more prominent role for price increases in explaining revenue growth, because list price inflation during this period was 10.9%, whereas net price inflation was 3.3%.

The Impact of Direct-to-Consumer Advertising on Outpatient Care Utilization
Matthew Eisenberg et al.
NBER Working Paper, December 2022 


There is much debate about the effects of pharmaceutical direct to consumer advertising (DTCA) on health care use. In this paper, we inform this debate by examining the effects of DTCA on office visits, as well as treatment courses resulting from those visits, for five common chronic conditions (hypertension, hyperlipidemia, diabetes, depression, and osteoporosis). In particular, we examine whether office visits result in use of drug therapy and/or continued office visits over time. We test these questions by combining data on pharmaceutical advertising from Nielsen with claims data from 40 large national employers, covering 18 million person-years. We analyze a non-elderly population by exploiting plausibly exogenous variation in advertising exposure across areas due to the implementation of Medicare prescription drug coverage which led to larger increases in advertising in areas with high elderly share of population compared to low elderly share areas. We find that advertising increases the number of office visits for the non-elderly for the advertised condition. We also find substantial spillovers -- a large share of the increased office visits from advertising are associated with use of non-advertised generic drugs or do not result in use of any drugs. Finally, we find that the increase in office visits due to DTCA is associated with continued engagement with a physician through multiple consecutive follow up visits over time.


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