Implementation Of Affordable Care Act Research Articles

Physician Reimbursement for Vascular Surgery Procedures and Vascular Laboratory Studies Before and After the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA), fully implemented by 2015, has significantly increased the number of Americans with health insurance. However, its impact on physician reimbursement (PR) is not well studied. Our objective was to determine the ACA's impact on the professional component of PR for selected vascular surgery (VS) procedures and vascular laboratory (VL) studies at our institution. PR for the following 5 VS procedures and 4 VL studies were obtained from our billing department: CPT 34803 (Endovascular aortic repair, EVAR), 35301 (carotid endarterectomy, CEA), 35656 (lower extremity bypass, LEB), 36010 (introduction of catheter into vena cava, ICVC), 36200 first, 93922 (ankle brachial index, ABI), 93925 (lower extremity arterial duplex, LEA duplex), 93970 (lower extremity venous duplex, LEV Duplex), and 93990 (hemodialysis duplex). The data was organized by payer: Medicare, Medicaid, Commercial Insurers (CI), and Other. PR was studied pre-ACA (January 2008 through December 2009) and post-ACA (January 2015 through December 2016). The post-ACA PR and inflation adjusted reimbursement (IAR) in 2016 dollars using the consumer price index (CPI) were calculated and compared using one-sample t-test. The percent difference between the post-ACA PR and IAR was also compared. PR for 1,637 VS procedures and 16,333 VL studies was analyzed. The post-ACA PR was significantly lower than the IAR for most Medicare and Medicaid procedures. For EVAR, post-ACA reimbursement was overall on par with the IAR but significantly lower for Medicare. For CEA, post-ACA reimbursement was overall lower than IAR. For LEB, overall average PR was lower than IAR, with statistically significant lower Medicare and Medicaid (P < 0.001) payments. For ICAo, overall PR was significantly lower than the IAR and this was true across all insurance types. In contrast, for ICV, the post-ACA reimbursement was higher than IAR for all payers but did not reach statistical significance (P=0.25). The post-ACA PR was significantly higher than the IAR for most VL studies, except for Medicare PR. The percent change for VS procedures were mostly negative for the Medicaid and Medicare groups. This results in potential annual shortcomings of $2, 862 and $20,923 respectively. When comparing reimbursement before and after ACA implementation, Medicare and Medicaid PR for most VS procedures has not kept up with inflation. However, for most VL procedures, PR has exceeded inflation. Further efforts are needed to support Vascular Surgery reimbursement including higher valuation of the Medicare Conversion factor.

Increasing Insurance Choices In The Affordable Care Act Marketplaces, 2018-21.

The Affordable Care Act (ACA) relies on insurers to offer health plans in the individual health insurance Marketplaces. Since the ACA's implementation, levels of Marketplace competition have varied, reaching a nadir in 2018. We examined the characteristics of counties that experienced changes in insurers' participation in the ACA Marketplaces from 2016 to 2021. Using data from the Kaiser Family Foundation and other sources, we found that 1,968 counties (accounting for 66percent of the US population younger than age sixty-five) have more insurers in 2021 than in 2018, whereas only twelve counties (comprising 0.4percent of the US nonelderly population) have fewer insurers. The number of counties with monopolist Marketplace insurers declined from 1,616 in 2018 to 294 in 2021. Recent Marketplace insurer gains were more likely in counties that lost insurers from 2016 to 2018 or had a monopolist insurer in 2018. Increased competition may lead to lower gross premiums in the ACA Marketplaces. Given the Biden administration's support for the ACA Marketplaces, it appears likely that the ACA individual health insurance market will be stable and profitable for the next several years.

Annual Wellness Visits for Persons With Physical Disabilities Before and After ACA Implementation.

Persons with disabilities often experience uncoordinated health care, with repeated out-of-pocket copays. One purpose of the Patient Protection and Affordable Care Act (ACA) was to create zero copays for preventive health care including an annual wellness visit (AWV). The purpose of this study was to document the use of AWVs by persons with physical disabilities during the ACA rollout. An administrative claims database, including both Medicare Advantage (MA) and commercial (COM) payers from 2008 to 2016, was used to identify unique wellness visits for adults with physical disabilities. We used interrupted time series analysis to compare AWV use by insurance type, sex, disability type, and race over time. The proportion of zero copays provided a timeline of ACA implementation categorized as pre-ACA, ACA-implementation, and post-ACA periods. By 2016, AWV use maximized at 47.6% (95% CI, 44.7%-50.8%) among COM-insured White women with congenital disabilities. By 2016, the lowest AWV use reached one-half the maximum, at 21.6% (95% CI, 18.4%-25.2%) among COM-insured Hispanic men with acquired disabilities. MA-insured Black and Hispanic men with acquired disabilities reached similarly low levels of AWV use. The ACA mandated zero copays, thereby allowing persons with physical disabilities the option for preventive health care without cost. Insurance type and sex significantly influenced AWV use, followed by disability type and race. Gaps in AWV use were exposed by insurance type, sex, disability, and race for persons with disabilities. Gaps in AWV use were also exposed between the general population and persons with disabilities.Annals "Online First" article.

Associations of Insurance Churn and Catastrophic Health Expenditures With Implementation of the Affordable Care Act Among Nonelderly Patients With Cancer in the United States

Health insurance coverage is dynamic in the United States, potentially changing from month to month. The Patient Protection and Affordable Care Act (ACA) aimed to stabilize markets and reduce financial burden, particularly among those with preexisting conditions. To describe the risks of insurance churn (ie, gain, loss, or change in coverage) and catastrophic health expenditures among nonelderly patients with cancer in the United States, assessing for changes associated with ACA implementation. This retrospective, cross-sectional study uses data from the Medical Expenditure Panel Survey, a representative sample of the US population from 2005 to 2018. Respondents included were younger than 65 years, identified by health care use associated with a cancer diagnosis code in the given year. Statistical analysis was conducted from July 30, 2020, to January 5, 2021. The Patient Protection and Affordable Care Act. Survey weights were applied to generate estimates for the US population. Annual risks of insurance churn (ie, any uninsurance or insurance change or loss) and catastrophic health expenditures (spending >10% income) were calculated, comparing subgroups with the adjusted Wald test. Weighted multivariable linear regression was used to assess for changes associated with ACA implementation. From 6069 respondents, we estimated a weighted mean of 4.78 million nonelderly patients (95% CI, 4.55-5.01 million; female patients: weighted mean, 63.9% [95% CI, 62.2%-65.7%]; mean age, 50.3 years [95% CI, 49.7-50.8 years]) with cancer annually in the United States. Patients with cancer experienced lower annual risks of insurance loss (5.3% [95% CI, 4.5%-6.1%] vs 7.6% [95% CI, 7.4%-7.8%]) and any uninsurance (14.6% [95% CI, 13.3%-16.0%] vs 24.1% [95% CI, 23.5%-24.7%]) but increased risk of catastrophic health expenditures (expenses alone: 12.4% [95% CI, 11.2%-13.6%] vs 6.3% [95% CI, 6.2%-6.5%]; including premiums: 26.6% [95% CI, 25.0%-28.1%] vs 16.5% [95% CI, 16.1%-16.8%]; P < .001) relative to the population without cancer. Patients with cancer from low-income families and with full-year private coverage were at particularly high risk of catastrophic health expenditures (including premiums: 81.7% [95% CI, 74.6%-88.9%]). After adjustment, low income was the factor most strongly associated with both insurance churn and catastrophic spending, associated with annual risk increases of 6.5% (95% CI, 4.2%-8.8%) for insurance loss, 17.3% (95% CI, 13.4%-21.2%) for any uninsurance, and 37.4% (95% CI, 33.3%-41.6%) for catastrophic expenditures excluding premiums (P < .001). In adjusted models relative to 2005-2009, full ACA implementation (2014-2018) was associated with a decreased annual risk of any uninsurance (-4.2%; 95% CI, -7.4% to -1.0%; P = .01) and catastrophic spending by expenses alone (-3.0%; 95% CI, -5.3% to -0.8%; P = .008) but not including premiums (0.4%; 95% CI, -2.8% to 4.5%; P = .82). In this cross-sectional study, US patients with cancer faced significant annual risks of insurance churn and catastrophic health spending. Despite some improvements with ACA implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship.

MP45-12 THE ASSOCIATION BETWEEN THE AFFORDABLE CARE ACT ON INSURANCE STATUS, CANCER STAGE, AND OVERALL SURVIVAL IN PATIENTS WITH RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance I (MP45)1 Sep 2021MP45-12 THE ASSOCIATION BETWEEN THE AFFORDABLE CARE ACT ON INSURANCE STATUS, CANCER STAGE, AND OVERALL SURVIVAL IN PATIENTS WITH RENAL CELL CARCINOMA Juan Javier-DesLoges, Kevin Hakimi, Julia Yuan, Shady Soliman, Margaret Meagher, Fady Ghali, Vinit Nawalade, Devin Patel, James Murphy, La Jolla, CA, Simon Kim, and Ithaar Derweesh Juan Javier-DesLogesJuan Javier-DesLoges More articles by this author , Kevin HakimiKevin Hakimi More articles by this author , Julia YuanJulia Yuan More articles by this author , Shady SolimanShady Soliman More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , Fady GhaliFady Ghali More articles by this author , Vinit NawaladeVinit Nawalade More articles by this author , Devin PatelDevin Patel More articles by this author , James MurphyJames Murphy More articles by this author , La Jolla, CALa Jolla, CA More articles by this author , Simon KimSimon Kim More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002066.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To determine whether insurance expansion implemented through the Affordable Care Act (ACA) were associated with changes in insurance coverage, stage at diagnosis, and survival in Renal Cell Carcinoma (RCC). METHODS: We analyzed RCC patients 40-64 years old between 2010 and 2016 in the National Cancer Database. States were categorized as participating on-time in Medicaid expansion or not participating, excluding late and early Medicaid expansion states. Patients were stratified into localized (Stage 1/2) and advanced (Stage 3/4) RCC and low-[(≤153% Federal Poverty Guidelines (FPG)], middle-(>153% to 241% FPG) and high-income (≥241% FPG)] groups. Stage trend analysis assessed for stage migration based on income status in expansion and non-expansion states. Cox Regression was assessed predictors for all-cause mortality (ACM) pre- and post-ACA. RESULTS: We analyzed 78,099 patients. Following ACA implementation, Absolute Percentage Change (APC) of patients with insurance increased in both expansion and non-expansion states by 4.0% and 2.1%, respectively. Largest increases occurred in expansion states, with increased acquisition of Medicaid by low-income (APC +11.0% p<0.001), middle-income (APC +4.2% p<0.001), and high-income (+4.0%, p<0.001). Stage trend analysis revealed higher proportions with localized RCC after ACA implementation in low-income (APC +4.0% p<0.001) and middle-income (APC +1.6% p=0.023) groups in expansion states. Cox Regression revealed that before ACA implementation, low-income was associated with higher risk of mortality (HR 1.29, p=0.001), which was attenuated following ACA (HR 1.10, p=0.201). CONCLUSIONS: ACA implementation has been associated with downward stage migration in low-income patients and attenuation of low-income status as a risk for mortality in RCC. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e807-e808 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Juan Javier-DesLoges More articles by this author Kevin Hakimi More articles by this author Julia Yuan More articles by this author Shady Soliman More articles by this author Margaret Meagher More articles by this author Fady Ghali More articles by this author Vinit Nawalade More articles by this author Devin Patel More articles by this author James Murphy More articles by this author La Jolla, CA More articles by this author Simon Kim More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement Loading ...

MP17-03 FACILITY-LEVEL FACTORS ASSOCIATED WITH DECREASING SHARE OF UROLOGIC CANCER PATIENTS WITH MEDICAID FOLLOWING IMPLEMENTATION OF THE AFFORDABLE CARE ACT

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures I (MP17)1 Sep 2021MP17-03 FACILITY-LEVEL FACTORS ASSOCIATED WITH DECREASING SHARE OF UROLOGIC CANCER PATIENTS WITH MEDICAID FOLLOWING IMPLEMENTATION OF THE AFFORDABLE CARE ACT Patrick Demkowicz, Matthew Buck, James Nie, Victoria Marks, and Michael Leapman Patrick DemkowiczPatrick Demkowicz More articles by this author , Matthew BuckMatthew Buck More articles by this author , James NieJames Nie More articles by this author , Victoria MarksVictoria Marks More articles by this author , and Michael LeapmanMichael Leapman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002002.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although the Affordable Care Act (ACA) expanded access to Medicaid, some hospitals may limit Medicaid patients due to lower reimbursement. Our study aims to understand how the proportion of urologic cancer patients with Medicaid changed across Commission on Cancer (CoC) facilities following ACA implementation. METHODS: We analyzed data from the National Cancer Database, which includes patients diagnosed at CoC facilities in the United States. We grouped patients aged 18-64 years and diagnosed between 2010-2017 with urologic cancers (prostate, urinary/bladder, kidney/renal pelvis, testis and penis) into distinct, deidentified facilities. We restricted our sample to facilities diagnosing ≥10 patients/year and excluded facilities in states that expanded Medicaid early or late. The primary outcome was the mean facility-level change in proportion of urologic cancer patients with Medicaid after ACA implementation (Jan 1, 2014) stratified by state Medicaid expansion status. We used multivariable logistic regression to determine the baseline clinical and demographic factors associated with a decrease in the proportion of a facility’s patients carrying Medicaid. RESULTS: We identified 630 facilities (287 expansion and 343 non-expansion) treating 436,082 urologic cancer patients. The mean facility-level change in proportion of patients with Medicaid was +5.8% (95% CI 5.0-6.5%) in expansion states vs. +0.6% (95% CI 0.2-0.9%) in non-expansion states. Despite overall increases, 13.6% of facilities in expansion states and 40.8% in non-expansion states experienced reductions (p <0.001). Facility-level factors associated with a decreased proportion of patients with Medicaid included non-expansion status (OR 7.5, 95% CI 4.6-13, p <0.001), highest quartile baseline Medicaid coverage (OR 4.8, 95% CI 2.5-9.6, p <0.001) and highest quartile share of patients from zip codes with median household incomes ≥$63,000 (OR 3.3, 95% CI 1.6-6.7, p <0.001). CONCLUSIONS: Despite a national increase in Medicaid coverage after ACA implementation, a subset of CoC facilities saw relatively fewer Medicaid patients. These findings may reflect disparities among urologic cancer patients with Medicaid in their ability to receive care at the facilities of their choosing. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e308-e309 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick Demkowicz More articles by this author Matthew Buck More articles by this author James Nie More articles by this author Victoria Marks More articles by this author Michael Leapman More articles by this author Expand All Advertisement Loading ...

The Impact of the Affordable Care Act Insurance Expansions on Opioid‐Related Emergency Department Visits

Research ObjectiveAmid rising opioid‐related deaths and hospital use, the 2010 Patient Protection and Affordable Care Act (ACA) was signed into law, with the central coverage provisions implemented in 2014. Because lack of health insurance is a barrier to opioid use disorder treatment, and because opioid use disorder treatment can prevent opioid‐related emergency department (ED) visits, we explore the impact of ACA Medicaid expansion and ACA marketplace insurance expansions on opioid‐related ED visits.Study DesignWe use ZIP Code‐level ED utilization data from the 2010–2018 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and State Emergency Department Databases (SEDD) for 29 states, while also accounting for the implementation of relevant state‐level policies using information from sources such as the Kaiser Family Foundation and the Prescription Drug Abuse Policy System. We control for area‐level sociodemographic information using from sources such as the Bureau of Labor Statistics and the Census. We use a difference‐in‐differences (DD) estimation strategy as well as a within‐state dose–response, difference‐in‐differences‐in‐differences (DDD) model based on pre‐ACA uninsurance levels to estimate impacts of the ACA in each of the five years following the 2014 insurance expansions.Population StudiedWe use data on ED visits among nonelderly adults from 2010–2018 for 17 states that adopted Medicaid expansion on January 1, 2014 (Arizona, California, Connecticut, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, North Dakota, Ohio, Rhode Island, and Vermont) and 12 states that did not implement Medicaid expansion during the study period (Florida, Georgia, Kansas, Maine, Missouri, Nebraska, North Carolina, South Carolina, South Dakota, Tennessee, Utah, and Wisconsin).Principal FindingsWe find that ACA coverage expansions reduced opioid‐related ED visits, but the effect varies over time. Relative to non‐expansion states, opioid‐related ED visit rates in expansion states remain the same or decrease slightly in the first three years after Medicaid expansion (2014–2016). A more marked decline emerges in the fourth and fifth years (2017–2018) after Medicaid expansion. Both DD and DDD results show strong evidence that the impact of ACA insurance expansions on opioid‐related ED visits grew over time.ConclusionsWe find that ACA insurance expansions reduced opioid‐related ED visit rates, with an effect that grows over time. As time from ACA implementation increases, aggregate effects of lower out‐of‐pocket prices, improved access to care, and supply responses would most likely produce reductions in opioid‐related ED visits, which we find in the fourth and fifth year after ACA implementation. These dynamics help explain why studies examining shorter post‐ACA periods or that were unable to estimate time‐varying impacts did not detect significant impacts of coverage expansions on opioid‐related ED visits.Implications for Policy or PracticeThere are likely to be lags between the time when an individual with substance use disorder (or at risk of developing the disorder) gains coverage, the time when the individual accesses treatment, and consequent reductions in ED visits. Our findings suggest that there are similarly important dynamics in the impact of insurance expansion on opioid‐related ED visits.

Churn and catastrophe: insurance loss and high spending among patients with gynecologic cancer in the United States in the era of the Affordable Care Act

<h3>Objectives:</h3> Although often considered a static characteristic in oncology research, insurance coverage is dynamic in reality, potentially changing month-to-month. The Affordable Care Act (ACA) was passed in 2010 with aims of stabilizing and expanding insurance markets, and reducing financial burden, particularly for the poor and sick. We sought to assess insurance churn and catastrophic health expenditures (CHE) among patients with gynecologic cancer in the era of the ACA. <h3>Methods:</h3> Retrospective study of 2006-2017 Medical Expenditure Panel Survey (MEPS) respondents under age 65 reporting care in the given year related to a gynecologic cancer diagnosis. MEPS is an annual survey representative of the civilian, non-institutionalized US population. Weights were applied to estimate national rates of insurance churn (loss/change of coverage) and CHE (family out-of-pocket health spending >10% family income), and differences between subgroups and over time were assessed by the adjusted Wald test. <h3>Results:</h3> A total of 684 MEPS respondents under age 65 reported care related to a gynecologic cancer diagnosis in 2006-2017, representing an estimated average annual population of 533,000 persons (95% CI 462,000-603,000), which was majority White (87.0%) and non-Hispanic (85.5%). Relative to the overall under 65 US population, patients with gynecologic cancer reported higher rates of low-income (family income ≤250% federal poverty level; 45.1% vs 32.2%; <i>p</i><0.001) and employment disruption (15.2% job change/loss, 55.3% part-year unemployment, 38.6% full-year unemployment, vs 10.5%, 44.1%, and 32.4% respectively; <i>p</i><0.05 for all). In the era of the ACA since becoming law in 2010, patients with gynecologic cancer reported high annual rates of insurance churn: 8.8% (95% CI 5.2-12.5) with loss of insurance, 18.7% (95% CI 13.6-23.8) with change in insurance, 21.7% (95% CI 16.5-26.9) uninsured for at least one month, and 8.4% (95% CI 5.7-11.0) uninsured for entire year. The gynecologic cancer population also experienced high rates of catastrophic spending, with 12.8% (95% CI 8.9-16.7) reporting CHE by out-of-pocket expenses alone, and 28.0% (95% CI 21.6-34.4) when including premium spending. Non-white and Hispanic patients collectively reported elevated rates of insurance churn (25.9% insurance change, 30.2% any uninsurance, vs 16.3% and 18.7% respectively for non-Hispanic whites, <i>p</i><0.05 for both), but no difference in rates of CHE. Patients from low-income families faced significantly higher risk of CHE (22.7% vs 3.0% expenses alone, <i>p</i><0.001; 35.3% vs 20.8% including premiums, <i>p</i>=0.01). Full-year Medicaid coverage was more protective from CHE compared with full-year private coverage (overall 15.3% vs 31.3%, <i>p</i>=0.02; low-income 11.5% vs 62.1%, <i>p</i><0.001). In assessment for impact of the ACA comparing full ACA implementation in 2014-17 with pre-ACA years 2006-09, we observed trends towards lower rates of CHE among low-income gynecologic cancer patients after implementation, but no significant differences. <h3>Conclusions:</h3> Gynecologic cancer patients face high rates of insurance churn, with over one in five reporting uninsurance for least one month every year, and catastrophic health spending, with over one in four reporting CHE annually. Low-income patients face the highest risks of CHE, and are better protected with Medicaid coverage as compared to private insurance. There was no significant impact of the ACA, but small sample size limited estimate precision and power to detect small changes.

Evaluation of Insurance Coverage and Cancer Stage at Diagnosis Among Low-Income Adults With Renal Cell Carcinoma After Passage of the Patient Protection and Affordable Care Act

The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown. To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income. This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not. Implementation of the ACA. The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed. The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, -1.14% [95% CI, -1.98% to -1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001). Implementation of the ACA was also associated with an increase in detection of stage I and II disease (APC, 4.0% [95% CI, 1.6%-6.3%]; P = .001) among low-income patients in expansion states. Among patients with RCC, ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states. The proportion of patients with localized disease increased among low-income patients in both states. These data suggest that ACA implementation is associated with earlier RCC detection among lower-income patients.

Affordable Care Act and Cancer Survivors' Financial Barriers to Care: Analysis of the National Health Interview Survey, 2009-2018.

Since Affordable Care Act (ACA) implementation in 2014, studies have demonstrated gains in insurance coverage for cancer survivors < 65 years. We assessed the impact of ACA implementation on financial barriers to care by stratifying survivors at age 65 years, when individuals typically become Medicare-eligible. We used data from respondents with cancer in the 2009-2018 National Health Interview Survey. We identified 21,954 respondents representing approximately 7.4 million survivors, who were then age-stratified at age 65 years. Survey responses regarding financial barriers to medical care and medications were analyzed, and age-stratified multivariable logistic regression modeling was performed, which evaluated the impact of ACA implementation on these measures, adjusted for demographic and socioeconomic variables. After multivariable logistic regression, ACA implementation was associated with higher adjusted odds of Medicaid insurance (odds ratio [95% CI] 2.02 [1.72 to 2.36]; P < .0001) and lower adjusted odds of no insurance (0.57 [0.48 to 0.68]; P < .0001). Regarding financial barriers, ACA implementation was associated with lower adjusted odds of inability to afford medications (0.68 [0.59 to 0.79]; P < .0001), inability to afford dental care (0.83 [0.73 to 0.94]; P = .004), and delaying care (0.78 [0.69 to 0.89]; P = .002) in the 18-64 years group. Similarly, ACA implementation was associated with lower adjusted odds of secondary outcomes such as delaying refills, skipping doses, and anxiety over medical bills. Similar associations were not seen in the > 65 years group. Survivor-reported measures of financial barriers in cancer survivors age 18-64 years significantly improved following ACA implementation. Similar changes were not seen in the Medicare-eligible cohort, likely because of high Medicare enrollment and few uninsured.

Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation

IntroductionBlack people in the United States who use opioids receive less treatment and die from overdoses at higher rates than White people. Medication for opioid use disorder (MOUD) decreases overdose risk. Implementation of the Affordable Care Act (ACA) in the United States was associated with an increase in MOUD. To what extent racial disparity exists in MOUD following ACA implementation remains unclear. Using a national sample of people seeking treatment for opioids (clients), we compared changes in MOUD after the ACA to determine whether implementation was associated with increased MOUD for Black clients relative to White clients. MethodsWe identified 878,110 first episodes for clients with opioids as primary concern from SAMHDA's Treatment Episodes Dataset-Admissions (TEDS-A; 2007–2018). We performed descriptive and logistic regression analyses to estimate odds of MOUD for Black and White clients by Medicaid expansion status. We interacted ACA implementation with racial group and performed subpopulation analyses for Medicaid enrollees and criminal justice–referred clients. ResultsIn expansion states post-ACA, MOUD increased from 33.6% to 51.3% for White clients and from 36.2% to 61.7% for Black clients. Pre-ACA, Black clients were less likely than White clients to use MOUD (adjusted odds ratio (aOR) = 0.88, 99th Confidence Interval (CI) = [0.85, 0.91]), and post-ACA, the change in odds of MOUD did not differ. Criminal justice–referred clients experienced less of a change in odds of MOUD among Black clients than among White clients (aOR = 0.74, CI = [0.62, 0.89]). Among Medicaid-insured clients, the change in odds of MOUD among Black clients was larger (aOR = 1.16, CI = [1.03, 1.30]). In the non–expansion states before 2014, Black clients were less likely to receive MOUD (aOR = 0.86, CI = [0.77, 0.95]) than White clients. After 2014, the change in odds of MOUD increased more for Black clients relative to White clients (aOR = 1.24, CI = [1.07, 1.44]). We did not find significant changes in MOUD for clients referred through the criminal justice system or with Medicaid. ConclusionThe ACA was associated with increased use of MOUD among Black clients and reduction in treatment disparity between Black and White clients. For criminal justice–referred Black clients, disparities in MOUD persist. Black clients with Medicaid in expansion states had the greatest reduction in disparities.

Association of the Affordable Care Act with survival among adolescents and young adults with lymphomas in California.

6532 Background: Our recent study showed that the implementation of the Affordable Care Act (ACA) was associated with increased health insurance coverage among adolescents and young adults (AYAs, 15–39 years) diagnosed with lymphomas in California and decreased likelihood of late stage at diagnosis. However, AYAs of Black or Hispanic race/ethnicity (vs Whites) and those living in lower socioeconomic (SES) neighborhoods were at higher risk of presenting with advanced stage. We aimed to determine whether the increased insurance coverage under the ACA was associated with improved survival, and to identify the main predictors of survival among AYAs with lymphomas. Methods: We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non-Hodgkin (NHL) or Hodgkin (HL) lymphoma during March 2005–September 2010 (pre-ACA), October 2010–December 2013 (early ACA) or 2014–2017 (full ACA). Patients were followed from lymphoma diagnosis until death, loss to follow-up or end of the study (12/31/2018). Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsured, other public or private. We used multivariable Cox proportional regression to examine the associations between all-cause survival and era of diagnosis, adjusting for sex, age and stage at diagnosis, health insurance, race/ethnicity, neighborhood SES, treatment facility, comorbidities, and marital status. Results: Of 11,221 AYAs, 5,878 were diagnosed with NHL and 5,343 with HL. Most patients were male (56%), White (45%), presented with earlier stage (I/II, 56%), and had private insurance (57%). The proportion of AYAs who received initial care at National Cancer Institute-Designated Cancer Centers (NCI-CCs) increased from 24% pre-ACA to 31% after full ACA implementation (p &lt; 0.001). AYAs diagnosed in the early (aHR = 0.76, 95% CI 0.67–0.88) and full ACA (aHR = 0.55, 95%CI 0.47–0.64) eras had better survival than those diagnosed pre-ACA. Compared to those with private insurance, survival was worse among patients with no insurance (HR = 2.13, 95% CI 1.83–2.49), discontinuous Medicaid (HR = 2.17, 95% CI 1.83–2.56) and continuous Medicaid (HR = 1.93, 95% CI 1.63–2.29) at diagnosis. Regardless of their insurance, older AYAs, males, unmarried, those with later stage (II–IV), residents in lower SES neighborhoods, and those of Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native race/ethnicity experienced worse survival. Conclusions: Following the ACA implementation in California, AYAs diagnosed with lymphomas experienced increased access to care at NCI-CCs and improved survival. Yet, racial/ethnic and socioeconomic survival disparities persisted. Moving forward, policy actions are required to mitigate structural and social determinants of health disparities in this population.

Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act.

BackgroundDespite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans’ financial risk protection has not been explored.ObjectiveTo evaluate whether ACA implementation was associated with changes in veterans’ risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA.DesignUsing multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18–64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending.ParticipantsNationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey.InterventionACA implementation, January 1, 2014.Main MeasuresLikelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income.Key ResultsAmong veterans aged 18–64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, −1.4 percentage points [pp]; 95% CI, −2.6 to −0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, −1.8pp; 95% CI, −3.0 to −0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans’ spending post-ACA include dental care, prescription drugs, and home care.ConclusionsACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans’ financial protection and areas amenable to policy intervention.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06807-4.

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York. We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses. After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries. Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.

The Association of the Affordable Care Act With Medicaid Enrollment Status and Costs of Care at a Level I Trauma Center in a Medicaid Non-expansion State.

The intended purpose of the Patient Protection and Affordable Care Act (ACA) was to expand access to health care insurance for all Americans. In our study, we examine the association of Medicaid enrollment status, health care outcomes, and financial outcomes for trauma patients at a level I urban trauma center in a state that did not expand Medicaid coverage under the ACA. We retrospectively reviewed trauma admissions from 2011 to 2016, via the trauma registry (n = 36,250). A subgroup of Medicaid patients (n = 8840) was identified and compared for changes in selected variables and demographics following ACA implementation. The association of Medicaid payor status, by 3year average pre-ACA (n = 3516) and post-ACA (n = 3324), on patient outcomes, payments collected, and accrued costs of care were analyzed. Three-year Medicaid median actual payments decreased 7.5% following implementation of the ACA ($4072 vs. $3767, P < .01). In contrast, the Medicaid median total cost of care increased 23% ($3964 vs. $4882, P < .01). The rate of patients insured by Medicaid decreased (24.0% vs. 16.2%, P<.001). Patients were admitted longer (1d vs. 2d, P < .01), and more injured (ISS 5 vs. 6, P < .01). Medicaid payor status under the ACA was associated with a decrease in actual payments and an increase in total cost of care. Moreover, the divergence in actual payments collected with the increased total cost of care warrants examination to ascertain the root cause in efforts to reduce this widening gap.

Access to care and health insurance coverage for workers with disabilities: Outcomes by state-level responses to the ACA

BackgroundStates had flexibility in their implementation of the Patient Protection and Affordable Care Act (ACA) Medicaid expansions, which may have led to variation in coverage and changes in access to care for workers with disabilities. Objective/hypothesisTo examine differential trends in health insurance coverage and access to care among workers with disabilities by states’ decisions about expanding Medicaid under the ACA. MethodsWe aggregated data from the National Health Interview Survey into groups by time period relative to ACA implementation: pre-ACA (2006–2009), early ACA (2010–2013), and later ACA (2014–2017). We produced health insurance and access statistics for each time period, by state-level Medicaid expansion status. ResultsUninsurance rates decreased after 2014 in all states, regardless of the state’s decision whether to expand Medicaid. There was a substantial increase after 2014 in the share of workers with disabilities covered by Medicaid in states that expanded in that year; in other states, workers with disabilities experienced larger increases in privately purchased coverage. At the same time, the share of workers with disabilities reporting cost-related barriers to care declined markedly in 2014 Medicaid expansion states, but it increased slightly in the non-expansion states. Structural barriers to accessing care increased in all states, with the smallest increase in 2014 expansion states. ConclusionsMedicaid coverage and cost-related access to care improved significantly among workers with disabilities in 2014 Medicaid expansion states, both overall and relative to workers with disabilities in non-expansion states.

The association between the Affordable Care Act on insurance status, cancer stage, and overall survival in patients with renal cell carcinoma.

281 Background: We aimed to determine whether insurance expansions implemented through the Patient Protection and Affordable Care Act (ACA) were associated with changes in insurance coverage status, stage at diagnosis, and overall survival for patients with renal cell carcinoma (RCC). Methods: We identified patients 40 to 64 years old diagnosed with RCC between 2010 and 2016 in the National Cancer Database. States were categorized as participating on time in Medicaid expansion or not participating. We stratified patients into advanced cancer (stage III + IV) and localized cancer (stage I + II) groups. We stratified patients into low, middle, and high income groups. Stage trend and insurance trend analysis were performed to based on income status amongst patients living in expansion and non-expansion states. Absolute percentage change (APC) was calculated for insurance status and stage migration. Cox Regression Multivariable Analysis was conducted to assess risk of all-cause mortality (ACM) for patients before and after the implementation of the ACA, adjusting for insurance status, income, education, age, race, ethnicity, comorbidity, and living in an expansion state. Results: We identified 78,099 patients who met inclusion criteria. Following implementation of ACA, APC of patients with insurance increased in both Medicaid and non-expansion states by 4.0% and 2.10% (p&lt;0.01), respectively. The largest increases occurred in expansion states, with low income patients acquiring Medicaid (APC +11.0% p&lt;0.01), middle income patients acquiring Medicaid (APC +8.20% p&lt;0.01), and high-income patients acquiring Medicaid (APC +4.0% p&lt;0.01). In our stage trend analysis, there was a higher proportion of patients with localized stage disease after the implementation of the ACA in low income (APC +4.0% p&lt;0.01) and middle-income patients (APC +1.6% p=0.02.) who live in expansions states, as well as middle income patients in non-expansions states (APC 1.4% p=0.02). Cox Regression MVA revealed that before ACA implementation, low income and middle income were associated with higher risk of mortality (HR 1.29 95%CI 1.18-1.40 p&lt;0.01) and (HR 1.18 95% CI 1.10-1.26, p&lt;0.01, but was not following ACA implementation (p=0.20) and (p=0.05) respectively. Conclusions: Following the implementation of the ACA the proportion of patients with newly diagnosed RCC with health insurance increased with the largest effects seen in Medicaid expansions states. In addition, higher proportions of patients were diagnosed with localized disease in Medicaid expansion states amongst low- and middle-income patients. Furthermore, income status ceased being a risk factor for mortality following ACA implementation. Our findings suggest that ACA implementation has been associated with downward stage migration in low/middle-income patients and attenuation of income status as a risk for mortality in RCC.

Disparities in insurance coverage among hospitalized adult congenital heart disease patients before and after the Affordable Care Act.

Data are lacking regarding the insurance status of adults with congenital heart disease (ACHD). We investigated whether the Affordable Care Act (ACA) impacted insurance status among hospitalized ACHD, identified associated sociodemographic factors, and compared coverage to adults with other chronic childhood conditions. Serial cross-sectional analysis of National Inpatient Sample hospitalizations from 2007 to 2016 was performed for patients 18-64 years old. ACHD were identified using ICD-9/10-CM codes and compared to patients with sickle cell disease (SCD), cystic fibrosis (CF), and the general population. Age was dichotomized as 18-25 years (transition aged) or 26-64 years. Groups were compared by era (pre-ACA [January 2007-June 2010]; early-ACA [July 2010-December 2013], which eliminated pre-existing condition exclusions; and full-ACA [January 2014-December 2016]) using interrupted time series and multivariable Poisson regression analyses. Overall, uninsured hospitalizations decreased from pre-ACA (12.0%) to full-ACA (8.5%). After full ACA implementation, ACHD had lower uninsured rates than the general hospitalized population (6.0 vs. 8.6%, p < .01), but higher rates than those with other chronic childhood diseases (SCD [4.5%]; CF [1.6%]). Across ACA eras, transition aged ACHD had higher uninsured rates than older patients (8.9 vs. 7.6%, p < .01), and Hispanic patients remained less insured than other groups. Hospitalized ACHD were better insured than the general population but less insured than those with SCD or CF. Full ACA implementation was associated with improved insurance coverage for all groups, but disparities persisted for transition aged and Hispanic patients. Ongoing evaluation of the effects of insurance and health policy on ACHD remains critical to diminish health disparities.

Primary care for new vs established Medicaid enrollees.

To understand changes in primary care (PC) utilization in Medicaid and the Children's Health Insurance Program (CHIP) 3 years after the Affordable Care Act (ACA). Secondary data analysis using Medicaid/CHIP paid claims and managed care encounters. Pre-/post-ACA trends in total enrollment and PC visits among newly enrolled and established patients were analyzed in half-year increments from the first half of 2012 to the second half of 2016. After ACA expansion, there was a temporary surge in new Medicaid/CHIP enrollment (which included surges in pre-ACA eligibility categories) and slow, steady growth in total enrollment. The percentage of new enrollees completing a PC visit within 90, 180, and 365 days of enrollment fell markedly in the first half of 2014 and then rebounded to pre-ACA levels thereafter. Conversely, the percentage of new enrollees remaining enrolled at 90, 180, and 365 days spiked upward in the first half of 2014 and gradually fell thereafter. Among established enrollees, PC visits per person exhibited a downward trend throughout the post-ACA period, driven mostly by a decline in the percentage of individuals with any PC visits. The first 6 months of ACA implementation in New Jersey were marked by a surge in Medicaid/CHIP enrollment that extended beyond the ACA target population, greater enrollment retention, and apparent bottlenecks in PC delivery. After the initial surge, new enrollees used PC at rates at least as high as in the pre-ACA period, whereas established enrollees used PC at a declining rate throughout the post-ACA period. PC delivery for new enrollees may have limited the availability of services for some established enrollees.

Health Insurance Coverage Mandates: Colorectal Cancer Screening in the Post-ACA Era.

Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women (n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. PREVENTION RELEVANCE: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered "up-to-date". Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health.