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Many uninsured Americans are already eligible for free or low-cost public coverage through Medicaid or Children's Health Insurance Program (CHIP) but do not 'take up' that coverage. However, several other public programs, such as food stamps and unemployment insurance, also have less-than-complete take-up rates, and take-up rates vary considerably among programs. This article examines the take-up literature across a variety of programs to learn what effects nonfinancial features, such as administrative complexity, have on take-up. We find that making benefit receipt automatic is the most effective means of ensuring high take-up, while there is little evidence that stigma is important. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of managed care on Medicaid beneficiaries' satisfaction with, access to, and use of medical care during early implementation of an enrollment initiative.Design: Cross-sectional survey of a random sample of Medicaid beneficiaries in 5 managed care plans and in the conventional Medicaid program.Setting: New York, NY.Participants: Adults aged 18 to 64 years who received Medicaid insurance benefits through Aid to Families With Dependent Children or State Home Relief and had been enrolled in a managed care plan or receiving benefits under conventional Medicaid for at least 6 months. Of the 2500 enrollees in managed care plans and the 600 other beneficiaries in conventional Medicaid whom we surveyed, 1038 enrollees and 410 nonenrollees responded.Outcome Measures: Beneficiaries' ratings of overall satisfaction and 13 dimensions of satisfaction related to access, interpersonal and technical quality, and cost; reports of access, including regular source (location) of care, waiting time for appointment, waiting time in office, and ability to obtain care; and reports of use, including inpatient, emergency department, and ambulatory visits.Results: Compared with beneficiaries in conventional Medicaid, managed care enrollees in general gave higher ratings of satisfaction. The results were not consistent, however, between the proportion who were extremely satisfied and the proportion who were extremely dissatisfied. Managed care enrollees had significantly greater odds of being extremely satisfied (excellent and very good ratings), but fewer differences were statistically significant for levels of extreme dissatisfaction (fair and poor ratings). With regard to access, managed care enrollees had significantly greater odds of having a usual source of care (odds ratio [OR], 2.33) and seeing the same clinician there (OR, 2.72) and had significantly shorter appointment and office waiting times. Managed care and conventional Medicaid beneficiaries reported no significant differences in obtaining or delays in getting needed care and in inpatient or emergency department use.Conclusions: Medicaid managed care enrollees in New York City reported better access to care and higher levels of satisfaction compared with conventional Medicaid beneficiaries. Differences between these findings and those for privately insured populations highlight the pitfalls of generalizing from other groups to Medicaid for policy purposes. Given growing reliance on consumer satisfaction surveys for clinical and public policy, future research should focus on factors that explain extreme satisfaction vs extreme dissatisfaction. New York State's initiative, which has been associated with careful state and local monitoring, merits continuing evaluation as managed care enrollment grows and may become mandatory. [ABSTRACT FROM AUTHOR]

Medicare Advantage (MA) supplemental benefits offered at no or low premiums are a key value proposition for low-income beneficiaries. Despite nearly $20 billion in rebate payments to MA plans for funding supplemental benefits, their quality or enrollee access is not monitored. Using 2018-19 Medicare Current Beneficiary Survey data linked to MA plan data, we found that regardless of plan benefit generosity, low-income beneficiaries were more likely to report dental, vision, and hearing unmet needs because of cost. Enrollment in plans with higher corresponding-year (that is, the same year as unmet need measurement) star ratings was associated with lower dental unmet need. Income-related disparities in dental unmet needs were lower in the highest-rated plans. However, prior-year star ratings that determined plan payments were not associated with unmet needs or disparities in those needs. Policy makers should consider monitoring supplemental benefits for equity and access, and they should assess the value added by quality bonus payments to high-rated plans for beneficiaries' access.

This study examined the equity implications of high-deductible health plans within the context of racial and ethnic wealth disparities. Using restricted data from the Medical Expenditure Panel Survey, we evaluated the net worth (in 2011-18) and financial assets (in 2011-16) of families with private insurance and those in high-deductible health plans with and without an associated health savings account. Our results represent, to our knowledge, the first estimates of racial and ethnic wealth disparities within these populations. Results show that White households consistently held significantly more wealth than did Black and Hispanic households across income levels. In the lowest income quartile, White privately insured families had more than 350 percent more in financial assets than their Black counterparts. Low-income Black and Hispanic families with high-deductible health plans but no savings accounts had median financial assets ($2,200 and $2,000, respectively) that were well below the average family coverage deductible. Study findings highlight the role of systemic racial wealth disparities, beyond that of income, to establish a unique pathway whereby high deductibles can exacerbate health care inequities.

Objectives. To evaluate the effects of a comprehensive traffic safety policy-New York City's (NYC's) 2014 Vision Zero-on the health of Medicaid enrollees. Methods. We conducted difference-in-differences analyses using individual-level New York Medicaid data to measure traffic injuries and expenditures from 2009 to 2021, comparing NYC to surrounding counties without traffic reforms (n = 65 585 568 person-years). Results. After Vision Zero, injury rates among NYC Medicaid enrollees diverged from those of surrounding counties, with a net impact of 77.5 fewer injuries per 100 000 person-years annually (95% confidence interval = -97.4, -57.6). We observed marked reductions in severe injuries (brain injury, hospitalizations) and savings of $90.8 million in Medicaid expenditures over the first 5 years. Effects were largest among Black residents. Impacts were reversed during the COVID-19 period. Conclusions. Vision Zero resulted in substantial protection for socioeconomically disadvantaged populations known to face heightened risk of injury, but the policy's effectiveness decreased during the pandemic period. Public Health Implications. Many cities have recently launched Vision Zero policies and others plan to do so. This research adds to the evidence on how and in what circumstances comprehensive traffic policies protect public health. ( Am J Public Health . 2024;114(6):633-641. https://doi.org/10.2105/AJPH.2024.307617).

Policy responses to the March 31, 2023, expiration of the Medicaid continuous coverage provision need to consider the difference between self-reported Medicaid participation on government surveys and administrative records of Medicaid enrollment. The difference between the two is known as the "Medicaid undercount." The size of the undercount increased substantially after the continuous coverage provision took effect in March 2020. Using longitudinal data from the Current Population Survey, we examined this change. We found that assuming that all beneficiaries who ever reported enrolling in Medicaid during the COVID-19 pandemic public health emergency remained enrolled through 2022 (as required by the continuous coverage provision) eliminated the worsening of the undercount. We estimated that nearly half of the 5.9 million people who we projected were likely to become uninsured after the provision expired, or "unwound," already reported that they were uninsured in the 2022 Current Population Survey. This finding suggests that the impact of ending the continuous coverage provision on the estimated uninsurance rate, based on self-reported survey data, may have been smaller than anticipated. It also means that efforts to address Medicaid unwinding should include people who likely remain eligible for Medicaid but believe that they are already uninsured.

Improving housing quality may improve residents' health, but identifying buildings in poor repair is challenging. We developed a method to improve health-related building inspection targeting. Linking New York City Medicaid claims data to Landlord Watchlist data, we used machine learning to identify housing-sensitive health conditions correlated with a building's presence on the Watchlist. We identified twenty-three specific housing-sensitive health conditions in five broad categories consistent with the existing literature on housing and health. We used these results to generate a housing health index from building-level claims data that can be used to rank buildings by the likelihood that their poor quality is affecting residents' health. We found that buildings in the highest decile of the housing health index (controlling for building size, community district, and subsidization status) scored worse across a variety of housing quality indicators, validating our approach. We discuss how the housing health index could be used by local governments to target building inspections with a focus on improving health.

While a large body of evidence has examined hospital concentration, its effects on health care for low-income populations are less explored. We use comprehensive discharge data from New York State to measure the effects of changes in market concentration on hospital-level inpatient Medicaid volumes. Holding fixed hospital factors constant, a one percent increase in HHI leads to a 0.6% (s.e. = 0.28%) decrease in the number of Medicaid admissions for the average hospital. The strongest effects are on admissions for birth (-1.3%, s.e. = 0.58%). These average hospital-level decreases largely reflect redistribution of Medicaid patients across hospitals, rather than overall reductions in hospitalizations for Medicaid patients. In particular, hospital concentration leads to a redistribution of admissions from non-profit hospitals to public hospitals. We find evidence that for births, physicians serving high shares of Medicaid beneficiaries in particular experience reduced admissions as concentration increased. These reductions may reflect preferences among these physicians or reduced admitting privileges by hospitals as a means to screen out Medicaid patients., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier B.V.)

Mild and moderate mental illnesses can hinder labor force participation, lead to work interruptions, and hamper earning potential. Targeted interventions have proven effective at addressing these problems. But their potential depends on labor protections that enable people to take advantage of these interventions while keeping jobs and income.

Importance: Given higher reimbursement rates, hospitals primarily serving privately insured patients may invest more in intensive coding than hospitals serving publicly insured patients. This may lead these hospitals to code more diagnoses for all patients., Objective: To estimate whether, for the same Medicaid enrollee with multiple hospitalizations, a hospital's share of privately insured patients is associated with the number of diagnoses on claims., Design, Setting, and Participants: This cross-sectional study used patient-level fixed effects regression models on inpatient Medicaid claims from Medicaid enrollees with at least 2 admissions in at least 2 different hospitals in New York State between 2010 and 2017. Analyses were conducted from 2019 to 2021., Exposures: The annual share of privately insured patients at the admitting hospital., Main Outcomes and Measures: Number of diagnostic codes per admission. Probability of diagnoses being from a list of conditions shown to be intensely coded in response to payment incentives., Results: This analysis included 1 614 630 hospitalizations for Medicaid-insured patients (mean [SD] age, 48.2 [20.1] years; 829 684 [51.4%] women and 784 946 [48.6%] men). Overall, 74 998 were Asian (4.6%), 462 259 Black (28.6%), 375 591 Hispanic (23.3%), 486 313 White (30.1%), 128 896 unknown (8.0%), and 86 573 other (5.4%). When the same patient was seen in a hospital with a higher share of privately insured patients, more diagnoses were recorded (0.03 diagnoses per percentage point [pp] increase in share of privately insured; 95% CI, 0.02-0.05; P < .001). Patients discharged from hospitals in the bottom quartile of privately insured patient share received 1.37 more diagnoses when they were subsequently discharged from hospitals in the top quartile, relative to patients whose admissions were both in the bottom quartile (95% CI, 1.21-1.53; P < .001). Those going from hospitals in the top quartile to the bottom had 1.67 fewer diagnoses (95% CI, -1.84 to -1.50; P < .001). Diagnoses in hospitals with a higher private payer share were more likely to be for conditions sensitive to payment incentives (0.08 pp increase for each pp increase in private share; 95% CI, 0.06-0.10; P < .001). These findings were replicated in 2016 to 2017 data., Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees, admission to a hospital with a higher private payer share was associated with more diagnoses on Medicaid claims. This suggests payment policy may drive differential investments in infrastructure to document diagnoses. This may create a feedback loop that exacerbates resource inequity.

Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.

Introduction: Although growing evidence links residential evictions to health, little work has examined connections between eviction and healthcare utilization or access. In this study, eviction records are linked to Medicaid claims to estimate short-term associations between eviction and healthcare utilization, as well as Medicaid disenrollment., Methods: New York City eviction records from 2017 were linked to New York State Medicaid claims, with 1,300 evicted patients matched to 261,855 non-evicted patients with similar past healthcare utilization, demographics, and neighborhoods. Outcomes included patients' number of acute and ambulatory care visits, healthcare spending, Medicaid disenrollment, and pharmaceutical prescription fills during 6 months of follow-up. Coarsened exact matching was used to strengthen causal inference in observational data. Weighted generalized linear models were then fit, including censoring weights. Analyses were conducted in 2019-2021., Results: Eviction was associated with 63% higher odds of losing Medicaid coverage (95% CI=1.38, 1.92, p<0.001), fewer pharmaceutical prescription fills (incidence rate ratio=0.68, 95% CI=0.52, 0.88, p=0.004), and lower odds of generating any healthcare spending (OR=0.72, 95% CI=0.61, 0.85, p<0.001). However, among patients who generated any spending, average spending was 20% higher for those evicted (95% CI=1.03, 1.40, p=0.017), such that evicted patients generated more spending on balance. Marginally significant estimates suggested associations with increased acute, and decreased ambulatory, care visits., Conclusions: Results suggest that eviction drives increased healthcare spending while disrupting healthcare access. Given previous research that Medicaid expansion lowered eviction rates, eviction and Medicaid disenrollment may operate cyclically, accumulating disadvantage. Preventing evictions may improve access to care and lower Medicaid costs., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Robotic prostatectomy is a costly new technology, but the costs may be offset by changes in treatment patterns. The net effect of this technology on Medicaid spending has not been assessed., Objective: To identify the association of the local availability of robotic surgical technology with choice of initial treatment for prostate cancer and total prostate cancer-related treatment costs., Design and Participants: This cohort study used New York State Medicaid data to examine the experience of 9564 Medicaid beneficiaries 40-64 years old who received a prostate biopsy between 2008 and 2017 and were diagnosed with prostate cancer. The local availability of robotic surgical technology was measured as distance from zip code centroids of patient's residence to the nearest hospital with a robot and the annual number of robotic prostatectomies performed in the Hospital Referral Region., Main Measures: Multivariate linear models were used to relate regional access to robots to the choice of initial therapy and prostate cancer treatment costs during the year after diagnosis., Key Results: The mean age of the sample of 9564 men was 58 years; 30% of the sample were White, 26% were Black, and 22% were Hispanic. Doubling the distance to the nearest hospital with a robot was associated with a reduction in robotic surgery rates of 3.7 percentage points and an increase in the rate of use of radiation therapy of 5.2 percentage points. Increasing the annual number of robotic surgeries performed in a region by 10 was associated with a decrease in the probability of undergoing radiation therapy of 0.6 percentage point and a $434 reduction in total prostate cancer-related costs per Medicaid patient., Conclusions: A full accounting of the costs of a new technology will depend on when it is used and the payment rate for its use relative to payment rates for substitutes., (© 2021. Society of General Internal Medicine.)

Importance: More evidence on associations between mandated paid sick leave and health service utilization among low-income adults is needed to guide health policy and legislation nationwide., Objective: To evaluate the association between New York City's 2014 paid sick leave mandate and health care utilization among Medicaid-enrolled adults., Design Setting and Participants: This retrospective cohort study used New York State Medicaid administrative data for adults 18 to 64 years old continuously enrolled in Medicaid from August 1, 2011, through July 31, 2017. A difference-in-differences approach with entropy balancing weights was used to compare New York City with the rest of New York State to assess the association of the paid sick leave mandate with health care utilization, and for those 40 to 64 years old, with preventive care utilization. The data analysis was performed from June through August 2020., Exposures: Temporal and spatial variation in exposure to the mandate., Main Outcomes and Measures: Annual health care utilization (emergency care, specialist visits, and primary care clinician visits) per Medicaid-enrolled adult. Secondary outcomes include categories of emergency utilization and utilization of 5 preventive services., Results: Of 552 857 individuals (mean [SD] age, 43 [12] years; 351 130 [64%] women) who met inclusion criteria, 99 181 (18%) were White, 162 492 (29%) Black, and 138 061 (25%) Hispanic. Paid sick leave was significantly associated with a reduction in the probability of emergency care (-0.6 percentage points [pp]; 95% CI, -0.7 to -0.5 pp; P  < .001), including a 0.3 pp reduction (95% CI, -0.4 to -0.2; P  < .001) in care for conditions treatable in a primary care setting and an increase in annual outpatient visits (0.124 pp; 95% CI, 0.040 to 0.208 pp; P  < .001). Among those 40 to 64 years old, the mandate was significantly associated with increased probabilities of glycated hemoglobin A 1c level testing (2.9 pp; 95% CI, 2.5-3.3 pp; P  < .001), blood cholesterol testing (2.7 pp; 95% CI, 2.5-2.9 pp; P  < .001), and colon cancer screening (0.4 pp; 95% CI, 0.2-0.6 pp; P  < .001)., Conclusions and Relevance: This retrospective cohort study of nonelderly adults enrolled in Medicaid New York State showed that mandated paid sick leave in New York City was significantly associated with differences in several dimensions of health care services use., Competing Interests: Conflict of Interest Disclosures: Drs Ko and Glied reported a grant from the Robert Wood Johnson Foundation’s Policies for Action program during the conduct of the study., (Copyright 2021 Ko H et al. JAMA Health Forum.)

Importance: The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient surgical care, particularly among underserved populations, remains unknown., Objective: To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care., Design, Setting, and Participants: This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019., Interventions: State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act., Main Outcomes and Measures: Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage., Results: A total of 207 176 patients (106 395 women [51.35%] and 100 781 men [48.65%]; mean [SD] age, 45.7 [12.4] years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states., Conclusions and Relevance: Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.

The Affordable Care Act was designed to provide financial protection to Americans in their use of the health care system. This required addressing two intertwined problems: cost barriers to accessing coverage and care, and barriers to comprehensive risk protection provided by insurance. We reviewed the evidence on whether the law was effective in achieving these goals. We found that the Affordable Care Act generated substantial, widespread improvements in protecting Americans against the financial risks of illness. The coverage expansions reduced uninsurance rates, especially relative to earlier forecasts; improved access to care; and lowered out-of-pocket spending. The insurance market reforms also made it easier for people to get and stay enrolled in coverage and ensured that those who were insured had true financial risk protection. But subsequent court decisions and congressional and executive branch actions have left millions uninsured and allowed the risk of inadequate insurance to resurface.

Although the pace of gentrification has accelerated in cities across the US, little is known about the health consequences of growing up in gentrifying neighborhoods. We used New York State Medicaid claims data to track a cohort of low-income children born in the period 2006-08 for the nine years between January 2009 and December 2017. We compared the 2017 health outcomes of children who started out in low-income neighborhoods that gentrified in the period 2009-15 with those of children who started out in other low-income neighborhoods, controlling for individual child demographic characteristics, baseline neighborhood characteristics, and preexisting trends in neighborhood socioeconomic status. Our findings suggest that the experience of gentrification has no effects on children's health system use or diagnoses of asthma or obesity, when children are assessed at ages 9-11, but that it is associated with moderate increases in diagnoses of anxiety or depression-which are concentrated among children living in market-rate housing.

Background: We report the rationale and design for a peer-evaluation protocol of attending congenital heart surgeon technical skill using direct video observation., Methods: All surgeons contributing data to The Society of Thoracic Surgeons-Congenital Heart Surgery Database (STS-CHSD) are invited to submit videos of themselves operating, to rate peers, or both. Surgeons may submit Norwood procedures, complete atrioventricular canal repairs, and/or arterial switch operations. A HIPPA-compliant website allows secure transmission/evaluation. Videos are anonymously rated using a modified Objective Structured Assessment of Technical Skills score. Ratings are linked to five years of contemporaneous outcome data from the STS-CHSD and surgeon questionnaires. The primary outcome is a composite for major morbidity/mortality., Results: Two hundred seventy-six surgeons from 113 centers are eligible for participation: 83 (30%) surgeons from 53 (45%) centers have agreed to participate, with recruitment ongoing. These surgeons vary considerably in years of experience and outcomes. Participants, both early and late in their careers, describe the process as "very rewarding" and "less time consuming than anticipated." An initial subset of 10 videos demonstrated excellent interrater reliability (interclass correlation = 0.85)., Conclusions: This study proposes to evaluate the technical skills of attending pediatric cardiothoracic surgeons by video observation and peer-review. It is notable that over a quarter of congenital heart surgeons, across a range of experiences, from almost half of United States centers have already agreed to participate. This study also creates a mechanism for peer feedback; we hypothesize that feedback could yield broad and meaningful quality improvement.

Democratic candidates for president in 2020 will likely include some type of public plan in their health care reform platforms. Existing public plans take many forms and often incorporate private elements, as do most proposals to extend such plans. We review the types of public plans in the current system. We describe and assess the range of proposals to extend these plans or elements of them to additional populations. We suggest questions that candidates could use to guide their decisions about the scope and content of their health policy proposals. Developmental work during campaigns will contribute to success in turning candidates' promises into accomplishments.

Issue: A current Republican legislative proposal would permit insurers to offer plans that exclude coverage of treatment for preexisting health conditions, even while the bill would maintain the Affordable Care Act’s rule prohibiting denial of coverage to people with a preexisting condition., Goal: Estimate patients’ out-of-pocket costs for five common preexisting conditions if the bill were to become law and assess any additional impact on out-of-pocket expenditures if spending on care for preexisting conditions no longer counted against plan deductibles., Methods: Analysis of 2014–2016 Medical Expenditure Panel Survey data for the privately insured adult population under age 65; and the proposed Ensuring Coverage for Patients with Pre-Existing Conditions Act (S. 3388)., Findings and Conclusion: If preexisting conditions were excluded from coverage, nearly all people with these conditions would see increased out-of-pocket costs. Average out-of-pocket costs for those with cancer or diabetes would triple, while costs for arthritis, asthma, and hypertension care would rise by 27 percent to 39 percent. Some individuals would see much larger increases: for example, 10 percent of diabetes patients could expect to incur over $9,200 annually in out-of-pocket costs. Many with preexisting conditions also would spend more on conditions that are not excluded, since out-of-pocket spending on their preexisting conditions would no longer count toward the deductible and out-of-pocket maximum.

Issue: The Affordable Care Act (ACA) made it easier for older adults and those with medical conditions to enroll in individual-market coverage by eliminating risk rating and limiting age rating. While the ACA also encourages young and healthy people to enroll through subsidies and the individual mandate, it’s not clear whether these incentives have been sufficient to prevent the risk pool from becoming disproportionately old and sick., Goal: To assess whether patterns in individual-market participation changed following ACA implementation., Methods: Comparison of Medical Expenditure Panel Survey (MEPS) data for the periods 2003–09 and 2014–15., Findings and Conclusion: The analysis found few differences in individual-insurance market participation before and after the ACA. Adverse selection occurred during both: people switching into individual insurance coverage after being uninsured were higher utilizers prior to the switch than were those who remained uninsured. Those who disenrolled from individual plans tended to be lower utilizers of care before switching compared with those who kept their coverage. The main difference was that more people--especially young adults--switched from Medicaid to individual insurance, and vice versa, after the ACA. Adverse enrollment or disenrollment in the individual market did not increase following ACA implementation. The combination of easing rating rules and encouraging participation appears to have maintained market stability.

Issue: With encouragement from the Trump administration, 14 states have received approval for or are pursuing work requirements for nondisabled Medicaid beneficiaries. The requirements have sparked controversy, including two legal challenges., Goal: To predict the effect of work requirements on the insurance coverage of Medicaid enrollees over time., Methods: Analysis of the coverage patterns of a national cohort of nondisabled adults in the federal Medical Expenditure Panel Survey. Their experience is applied to a similar cohort of adults in Kentucky (which has received approval for work requirements, subject to a legal challenge) to project the potential effects of work requirements on their insurance coverage., Findings and Conclusions: Adding a new administrative hurdle in the form of work requirements in Kentucky would double the number of enrollees who disenroll from the program over a two-year period. We estimate that as many as 118,000 adults enrolled in Medicaid would either become uninsured for an extended period of time or experience a gap in insurance over a two-year period. These findings should be of concern to policymakers: research has found that adults who experience coverage gaps report problems getting health care or paying medical bills at rates nearly as high as those who are uninsured continuously.

One often-discussed option for controlling Medicare spending is to switch to a premium-support design. This would shift part of the risk of future health care cost increases from the federal treasury to Medicare beneficiaries. The economics of risk bearing suggests that this would be a mistake for three reasons. First, political decisions, not beneficiary choices, are the critical determinants of future health care costs. Second, only Congress can take into account the consequences of cost-containment decisions for both current and future generations. Third, the federal government is best able to diversify against the risk of future cost growth. Tying Medicare spending to the government's budget so that Congress sees the benefits of tough cost containment choices is the only way to force the program to make those politically difficult decisions. Economic efficiency is served by retaining the program's current structure instead of shifting risk to beneficiaries.

Background: Significant disparities exist between patients of different races and with different family incomes; less is understood regarding community-level factors on outcomes., Methods: In this study, we used linked data from the Pediatric Health Information System database and the US Census Bureau to examine associations between median annual household income by zip code and mortality, length of stay, inpatient standardized costs, and costs per day, over and above the effects of race and payer, first for children undergoing cardiac surgery (2005-2015) and then for all pediatric discharges (2012-2015). Median community-level income was examined as continuous and categorical (by quartile) predictors. Hierarchical logistic and censored linear regression models were constructed. To these models, patient and surgical characteristics, year, race, payer, state, urban or rural designation, and center fixed effects were added., Results: We identified 101 013 cardiac surgical (and 857 833 total) hospitalizations from 46 institutions. Children from the lowest-income neighborhoods who were undergoing cardiac surgery had 1.18 times the odds of mortality (95% confidence interval [CI]: 1.03 to 1.35), 7% longer lengths of stay (CI: 1% to 14%), and 7% higher standardized costs (CI: 1% to 14%) than children from the highest-income neighborhoods. Results for all children were similar, both with and without any major chronic conditions. The effects of neighborhood were only partially explained by differences in race, payer, or the centers at which patients received care. There were no differences in costs per day., Conclusions: Children from lower-income neighborhoods are at increased risk of mortality and use more resource intensive care than children from higher-income communities, even after accounting for disparities between races, payers, and centers., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

The United States relies on competition to balance costs and quality in the health care system. But concentration is increasing throughout the hospital, physician, and insurer markets. Midsize community hospitals face declining demand and growing competition from both larger hospitals and smaller freestanding diagnostic and surgical centers, leaving the midsize hospitals vulnerable to closure or merger with other facilities. Competition among insurers has been limited by the development of hospital systems that extend the bargaining power of "must-have" hospitals (those perceived to provide the best care for complex and less common conditions) across local health care markets. Government antitrust enforcement could play an important role in maintaining competition in both the hospital and insurer markets, but in many markets, the impact of that enforcement has been limited to date. Policy makers should consider supplementing antitrust activities with strategies that combine competition and regulation-for example, by regulating selected prices and structuring competition to cover entire insurance markets., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Surgeon experience concerns both families of children with congenital heart disease and medical providers. Relationships between surgeon seniority and patient outcomes are often assumed, yet there are little data., Methods and Results: This national study used linked data from the American Medical Association Physician Masterfile and the Society of Thoracic Surgeons-Congenital Heart Surgery Database to examine associations between surgeon years since medical school and major morbidity/mortality for children undergoing cardiac surgery. Sensitivity analyses explored the effects of patient characteristics, institutional/surgeon volumes, and various measures of institutional surgeon team experience. In secondary analyses, major morbidity and mortality were examined as separate end points. We identified 206 congenital heart surgeons from 91 centers performing 62 851 index operations (2010-2014). Median time from school was 25 years (range 9-55 years). A major morbidity/mortality occurred in 11.5% of cases. In multivariable analyses, the odds of major morbidity/mortality were similar for early-career (<15 years from medical school, ≈<40 years old), midcareer (15-24 years, ≈40-50 years old), and senior surgeons (25-35 years, ≈50-60 years old). The odds of major morbidity/mortality were ≈25% higher for operations performed by very senior surgeons (35-55 years from school, ≈60-80 years old; n=9044 cases). Results were driven by differences in morbidity. In extensive sensitivity analyses, these effects remained constant., Conclusions: In this study of >200 congenital heart surgeons, we found patient outcomes for surgeons with the fewest years of experience to be comparable to those of their midcareer and senior colleagues, within the context of existing referral and support practices. Very senior surgeons had higher risk-adjusted odds of major morbidity/mortality. Contemporary approaches to training, referral, mentoring, surgical planning, and other support practices might contribute to the observed outcomes of junior congenital heart surgeons being comparable to those of more experienced colleagues. Understanding and disseminating these practices might benefit the medical community at large., (© 2017 American Heart Association, Inc.)

Recent increases in market concentration among health plans, hospitals, and medical groups raise questions about what impact such mergers are having on costs to consumers. We examined the impact of market concentration on the growth of health insurance premiums between 2014 and 2015 in two Affordable Care Act state-based Marketplaces: Covered California and NY State of Health. We measured health plan, hospital, and medical group market concentration using the well-known Herfindahl-Hirschman Index (HHI) and used a multivariate regression model to relate these measures to premium growth. Both states exhibited a positive association between hospital concentration and premium growth and a positive (but not statistically significant) association between medical group concentration and premium growth. Our results for health plan concentration differed between the two states: It was positively associated with premium growth in New York but negatively associated with premium growth in California. The health plan concentration finding in Covered California may be the result of its selectively contracting with health plans., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Hypoplastic left heart syndrome is the most expensive birth defect managed in the United States, with a 5-year survival rate below 70%. Increasing evidence suggests that hospital volumes are inversely associated with mortality for infants with single ventricles undergoing stage 1 surgical palliation. Our aim was to examine the relative effects of surgeon and institutional volumes on outcomes and resource utilisation for these children., Methods: A retrospective study was conducted using the Pediatric Health Information System database to examine the effects of the number of procedures performed per surgeon and per centre on mortality, costs, and post-operative length of stay for infants undergoing Risk Adjustment for Congenital Heart Surgery risk category six operations at tertiary-care paediatric hospitals, from 1 January, 2004 to 31 December, 2013. Multivariable modelling was used, adjusting for patient and institutional characteristics. Gaussian kernel densities were constructed to show the relative distributions of the effects of individual institutions and surgeons, before and after adjusting for the number of cases performed., Results: A total of 2880 infants from 35 institutions met the inclusion criteria. Mortality was 15.0%. Median post-operative length of stay was 24 days (IQR 14-41). Median standardized inpatient hospital costs were $156,000 (IQR $108,000-$248,000) in 2013 dollars. In the multivariable analyses, higher institutional volume was inversely associated with mortality (p=0.001), post-operative length of stay (p=0.004), and costs (p=0.001). Surgeon volume was associated with none of the measured outcomes. Neither institutional nor surgeon volumes explained much of the wide variation in outcomes and resource utilization observed between institutions and between surgeons., Conclusions: Increased institutional - but not surgeon - volumes are associated with reduced mortality, post-operative length of stay, and costs for infants undergoing stage 1 palliation.

Objectives: To compare the rates of hospital readmissions, emergency department, and outpatient clinic visits after discharge for robotically assisted (RA) versus nonrobotic hysterectomy in women age 30 or more with nonmalignant conditions., Data Sources: Discharges for 2011 for 8 states (CA, FL, GA, IA, MO, NE, NY, TN) (>86,000 inpatient hysterectomies) were drawn from the statewide databases of the Healthcare Cost and Utilization Project. Data from 4 of these states were used to study revisits after 29,000 outpatient hysterectomies., Methods: Matched pairs of patients were constructed with propensity scores derived from each patient's age group, severity of illness, insurance coverage, and type of procedure. Both the full set of revisits and a set limited to diagnoses for revisits judged in other research to be related to the initial surgery (about 70% of all revisits) were analyzed. The analyses were repeated with an instrumental variables regression design., Key Results: Using the propensity score matched pairs, revisits, and specifically readmissions, after inpatient hysterectomy were greater for RA versus non-RA patients (relative risk of readmission=124%, P<0.01). Similar results were found for readmissions after outpatient hysterectomy, and readmissions after inpatient hysterectomy for the restricted set of related revisits. In the method with instrumental variables, RA was associated with an increase of 32% in the likelihood of any revisit (P<0.01)., Conclusions: Using 2 different methods to control for selection, this study found higher rates of revisits among women undergoing RA versus non-RA hysterectomy for benign conditions. While selection bias cannot be ruled out completely in an observational study, the study supports broader use of revisits for analyses of outcomes of hysterectomy.

Two prior studies, conducted in 1966 and in 1979, examined the role of economic research in health policy development. Both concluded that health economics had not been an important contributor to policy. Passage of the Affordable Care Act offers an opportunity to reassess this question. We find that the evolution of health economics research has given it an increasingly important role in policy. Research in the field has followed three related paths over the past century-institutionalist research that described problems; theoretical research, which proposed relationships that might extend beyond existing institutions; and empirical assessments of structural parameters identified in the theoretical research. These three strands operating in concert allowed economic research to be used to predict the fiscal and coverage consequences of alternative policy paths. This ability made economic research a powerful policy force. Key conclusions of health economics research are clearly evident in the Affordable Care Act., (© The Author(s) 2015.)

Many recent public and private strategies aimed at improving the quality and efficiency of the U.S. health care system focus on measuring, reporting on, and providing incentives for improving quality. In behavioral health care, despite recent efforts, quality measurement for even the more common conditions is less well developed than for comparable general medical conditions. The absence of a comprehensive set of well-accepted measures capable of demonstrating the value of behavioral health treatment makes building a case for devoting resources to treatment more difficult. This Open Forum reviews the current state of behavioral health quality measurement, describes the criteria relevant to assessing measures, and provides a case for encouraging the development, collection, and routine use of functional outcome measures in behavioral health care.

Widespread dissemination of early interventions for psychosis, such as the intervention offered in the RAISE study (Recovery After an Initial Schizophrenia Episode), requires a funding mechanism that is both compatible with approaches already used by payers and generates incentives for providers that promote the desired behaviors. The authors propose a funding model with three components: a prospective per-case payment made conditional on patient engagement in treatment, a per-service component to cover the costs of clinical services, and an outcome-based component conditional on achieving measurable outcome milestones. The authors describe the components and how such a payment mechanism might be implemented.

About half of the $2.1 trillion of US health services spending constitutes compensation to employees. We examined how the wages paid to health-sector employees compared to those paid to workers with similar qualifications in other sectors. Overall, we found that health care workers are paid only slightly more than workers elsewhere in the US economy, but the patterns are starkly different for nonprofessional and professional employees. Nonprofessional health care workers earn slightly less than their counterparts elsewhere in the economy. By contrast, the average nurse earns about 40 percent more than the median comparable worker in a different sector. The average physician earns about 50 percent more than a comparable worker in another sector of the economy, and this differential has increased sharply since 1993. Cost containment is likely to lead to reductions in the earnings of health care professionals, but it will also require using fewer or less skilled employees to produce a given service., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Hypoplastic left heart syndrome (HLHS) is not only a devastating disease, but also the most expensive birth defect managed in the US. Nosocomial bloodstream infections (NBIs) are common in neonates with HLHS. We examined the effects of NBIs on in-hospital mortality, length of stay, and costs for late preterm and term infants with HLHS undergoing stage 1 palliation, at both individual patient and hospital levels., Methods: We conducted a retrospective study of infants 35 weeks or greater gestation with HLHS, admitted to our institution January 1, 2003 to January 1, 2013. Children with other cardiac abnormalities, major comorbid conditions, or perinatal infections were excluded. Univariable and multivariable analyses were performed. To estimate the effects of reduced NBI incidence on resource utilization, predictive models were used., Results: One hundred forty-three children met inclusion criteria. In-hospital mortality was 9.1% (n = 13). Postoperative infection was observed in 12.6% (n = 18). Median length of stay was 23 days for survivors (IQR, 17 to 40; range, 9 to 132). Median costs were $83,000 for survivors, in 2013 dollars (IQR, $62,000 to $123,000; range, $17,000 to $517,000). NBIs were not associated with changes in mortality. In multivariable analyses, at a patient level NBIs were associated with a 74% increase in length of stay (95% confidence interval [CI], 31% to 132%, p < 0.001) and a 65% increase in costs (95% CI, 28% to 114%, p < 0.001). On a hospital level, in this cohort a 50% reduction in the incidence of NBIs would be expected to yield a 4.3% decrease in average length of stay and a 3.8% decrease in average in-patient costs., Conclusions: Nosocomial bloodstream infections in neonates with HLHS are associated with large increases in lengths of stay and costs on a patient level, but not a hospital level. For hospitals without particularly high incidences, studies are needed to identify additional targets for quality improvement., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Observational studies comparing neoadjuvant chemotherapy to primary surgery for advanced-stage ovarian cancer are limited by strong selection bias. Multiple methods were used to control for confounding and selection bias to estimate the effect of primary treatment on survival for ovarian cancer., Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify women ≥ 65 years of age with stage II-IV epithelial ovarian cancer who survived > 6 months from the date of diagnosis and received treatment from 1991 through 2007. Traditional regression analysis, propensity score-based analysis, and an instrumental variable analysis (IVA) using geographic location as an instrument were used to compare survival between neoadjuvant chemotherapy and primary surgery., Results: A total of 9587 patients with stage II-IV ovarian cancer were identified. Use of primary surgery decreased from 63.2% in 1991 to 49.5% by 2007, whereas primary chemotherapy increased from 19.7% in 1991 to 31.8% in 2007 (P < .0001). In the observational cohort survival (hazard ratio [HR] = 1.27; 95% confidence interval [CI] = 1.19-1.35) was inferior for patients treated with neoadjuvant chemotherapy; both median survival (15.8 versus 28.8 months) and 2-year survival (36% versus 56%) were lower in the neoadjuvant chemotherapy group compared to those who underwent surgery. In the IVA, primary treatment had minimal effect on overall survival (HR = 1.04; 95% CI = 0.67-1.60). The median survival for patients with a value of the instrument less than the median (24.0 months, 95% CI = 23.0-25.0) and greater than or equal to median value of the IV (24.0 months, 95% CI = 23.0-26.0) were similar., Conclusions: Use of neoadjuvant therapy has increased over time. Survival with neoadjuvant chemotherapy did not differ significantly from primary surgery in elderly women in the United States., (© 2013 American Cancer Society.)

Prior to the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Patient Protection and Affordable Care Act (ACA), about 49 million Americans were uninsured. Among those with employer-sponsored health insurance, 2% had coverage that entirely excluded mental health benefits and 7% had coverage that entirely excluded substance use treatment benefits. The rates of noncoverage for mental and substance use disorder care in the individual health insurance markets are considerably higher. Private health insurance generally limits the extent of these benefits. The combination of MHPEA and ACA extended overall health insurance coverage to more people and expanded the scope of coverage to include mental health and substance abuse benefits.

Background: Prior literature suggests that the fragmented U.S. health care system places a large administrative burden on physicians. Less is known about how this burden varies with physician contracting practices., Objective: To assess the extent to which physician practice outcomes vary with the number of managed care contracts held or the availability of such contracts., Design, Participants, and Main Measures: We perform secondary data analyses of the first four rounds of the nationally representative Community Tracking Study Physician Survey (1996-2005), which includes 36,340 physicians (21,567 PCPs [primary care physicians] and 14,773 specialists) across the four survey periods. Our measures include reported hours in patient care, share of hours outside patient care, adequacy of time with patients, career satisfaction, and income., Results: Doctors who contract with more plans report spending more time in patient care (per 11 additional contracts, about 30 min per week for PCPs and 20 min per week for specialists), report spending a modestly larger share of their time outside patient care (per 11 additional contracts, about 10 min per week for PCPs and specialists), are slightly more likely to report inadequate time with patients (odds ratio 1.005 per additional contract for PCPs), and earn higher incomes (per 11 additional contracts, about 3 % more per year for specialists)., Conclusions: Contracting opportunities confer significant benefits on physicians, although they do add modest costs in terms of time spent outside patient care and lower adequacy of time with patients. Simplifications that reduce the administrative burden of contracting may improve care by optimizing allocation of physician effort.

Objective: Robotic technology has diffused rapidly despite high costs and limited additive reimbursement by major payers. We aimed to identify the factors associated with hospitals' decisions to adopt robotic technology and the consequences of these decisions., Methods: This observational study used data on hospitals and market areas from 2005 to 2009. Included were hospitals in census-based statistical areas within states in the State Inpatient Database that participated in the American Hospital Association annual surveys and performed radical prostatectomies. The likelihood that a hospital would acquire a robotic facility and the rates of radical prostatectomy relative to the prevalence of robots in geographic market areas were assessed using multivariable analysis., Results: Hospitals in areas where a higher proportion of other hospitals had already acquired a robot were more likely to acquire one (P=0.012), as were those with more than 300 beds (P<0.0001) and teaching hospitals (P<0.0001). There was a significant association between years with a robot and the change in the number of radical prostatectomies (P<0.0001). More radical prostatectomies were performed in areas where the number of robots per 100,000 men was higher (P<0.0001). Adding a single robot per 100,000 men in an area was associated with a 30% increase in the rate of radical prostatectomies., Conclusions: Local area robot competition was associated with the rapid spread of robot technology in the United States. Significantly more radical prostatectomies were performed in hospitals with robots and in market areas of hospitals with robotic technology.

Objectives: To examine regional variation in the service quality of physician practices and to assess the association of this variation with the supply and organization of physicians., Study Design: Secondary analyses of the Community Tracking Study (CTS) household and physician surveys., Methods: A total of 40,339 individuals who had seen a primary care physician because of an illness or injury and 17,345 generalist physicians across 4 survey time periods in 60 CTS sites were included. Service quality measures used were lag between making an appointment and seeing a physician, and wait time at the physician's office. Our supply measure was the physician-to-population ratio. Our organizational measure was the percentage of physicians in group practices. Multivariate regressions were performed to examine the relationship between service quality and the supply and organization of physicians., Results: There was substantial variation in the service quality of physician visits across the country. For example, in 2003, the average wait time to see a doctor was 16 minutes in Milwaukee but more than 41 minutes in Miami; the average appointment lag for a sick visit in 2003 was 1.2 days in west-central Alabama but almost 6 days in Northwestern Washington. Service quality was not associated with the primary care physician-to-population ratio and had varying associations with the organization of practices., Conclusions: Cross-site variation in service quality of care in primary care has been large, persistent, and associated with the organization of practices. Areas with higher primary care physician-to-population ratios had longer, not shorter, appointment lags.