Changes In Health Insurance Coverage Research Articles

Transitions in health insurance among continuously insured patients with schizophrenia

Changes in health insurance coverage may disrupt access to and continuity of care, even for those who remain insured. Continuity of care is especially important in schizophrenia, which requires ongoing medical and pharmaceutical treatment. However, little is known about continuity of insurance coverage among those with schizophrenia. The objective was to examine the probability of insurance transitions for individuals with schizophrenia who were continuously insured and whether this varied across insurance types. The Massachusetts All-Payer Claims Database identified individuals with schizophrenia aged 18–64 who were continuously insured during a two-year period between 2014 and 2018. A logistic regression estimated the association of having an insurance transition – defined as having a change in insurance type – with insurance type at the start of the period, adjusting for age, sex, ZIP code in the lowest quartile of median income, and ZIP code with concentrated poverty. Overall, 15.1% had at least one insurance transition across a 24-month period. Insurance transitions were most frequent among those with plans from the Marketplace. In regression adjusted results, individuals covered by the traditional Medicaid program were 20.2 percentage points [pp] (95% confidence interval [CI]: 24.6 pp, 15.9 pp) less likely to have an insurance transition than those who were insured by a Marketplace plan. Insurance transitions among individuals with schizophrenia were common, with more than one in six people having at least one transition in insurance type during a two-year period. Given that even continuously insured individuals with schizophrenia commonly experience insurance transitions, attention to insurance transitions as a barrier to care access and continuity is warranted.

The impact of COVID-19 on healthcare coverage and access in racial and ethnic minority populations in the United States.

This study described spatiotemporal changes in health insurance coverage, healthcare access, and reasons for non-insurance among racial/ethnic minority populations in the United States during the COVID-19 pandemic using four national survey datasets. Getis-Ord Gi* statistic and scan statistics were used to analyze geospatial clusters of health insurance coverage by race/ethnicity. Logistic regression was used to estimate odds of reporting inability to access healthcare across two pandemic time periods by race/ethnicity. Racial/ethnic differences in insurance were observed from 2010 through 2019, with the lowest rates being among Hispanic/Latino, African American, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander populations. Pre-pandemic insurance coverage rates were geographically clustered. The percentage of adults citing change in employment status as the reason for non-insurance increased by about 7% after the start of the pandemic, with a small decrease observed among African American adults. Almost half of adults reported reduced healthcare access in June 2020, with 38.7% attributing reduced access to the pandemic; however, by May 2021, the percent of respondents reporting reduced access for any reason and due to the pandemic fell to 26.9% and 12.7%, respectively. In general, racial/ethnic disparities in health insurance coverage and healthcare access worsened during the pandemic. Although coverage and access improved over time, pre-COVID disparities persisted with African American and Hispanic/Latino populations being the most affected by insurance loss and reduced healthcare access. Cost, unemployment, and eligibility drove non-insurance before and during the pandemic.

Aging out of dependent coverage and health insurance trends, 2014-2019.

To examine changes in health insurance coverage when adults age out of dependent coverage at age 26 after the implementation of most Affordable Care Act (ACA) provisions. Our analysis also documented differences by sex, race and ethnicity, and state Medicaid expansion status. We used a regression discontinuity design and the 2014-2019 American Community Survey to estimate coverage changes (uninsured, any private, employer-sponsored coverage, direct purchase, and Medicaid) at age 26. Our main sample consisted of adult citizens aged 22-29 years. Uninsurance increased by 2.7 percentage points [95% CI; 1.8 to 3.4] at age 26, which was driven by a significant decline in any private insurance (3.7 percentage point decrease). Young adults experienced a smaller increase in the uninsured rate on turning age 26 in states that expanded in 2014 compared to nonexpansion states (2.2 and 3.2 percentage point increases, respectively), but the difference was not significant (P=0.07). Changes in the uninsured rate at age 26 did not differ significantly by sex or race and ethnicity. The 2010 dependent coverage provision led to more coverage options among young adults and in turn the uninsured rate declined among a population historically among the most likely to lack coverage. The 2014 Medicaid and Marketplace expansions reduced the uninsured rate even further among young adults. Despite important progress, our findings for 2014-2019 were similar to previous studies using pre-ACA data suggesting that coverage loss remains a risk when adults age out of dependent coverage at age 26.

Association between Medicare eligibility at age 65 years and in-hospital treatment patterns and health outcomes for patients with trauma: regression discontinuity approach

ObjectiveTo determine whether health systems in the United States modify treatment or discharge decisions for otherwise similar patients based on health insurance coverage.DesignRegression discontinuity approach.SettingAmerican College of Surgeons’ National Trauma...

Healthcare utilization patterns for knee and hip osteoarthritis before and after changes in national health insurance coverage: a data linkage study from the Netherlands

IntroductionMedical guidelines aim to stimulate stepped care for knee and hip osteoarthritis, redirecting treatments from hospitals to primary care. In the Netherlands, this development was supported by changing health insurance coverage for physio/exercise therapy. The aim of this study was to evaluate healthcare utilization patterns before and after health changes in health insurance coverage. MethodWe analyzed electronic health records and claims data from patients with osteoarthritis in the knee (N = 32,091) and hip (N = 16,313). Changes between 2013 and 2019 in the proportion of patients treated by the general practitioner, physio/exercise therapist or orthopedic surgeon within 6 months after onset were assessed. ResultsJoint replacement surgeries decreased for knee (OR 0.47 [0.41–0.54]) and hip (OR 0.81 [0.71–0.93]) osteoarthritis between 2013–2019. The use of physio/exercise therapy increased (knee: OR 1.38 [1.24–1.53], hip: OR 1.26 [1.08–1.47]). However, the proportion treated by a physio/exercise therapist decreased for patients that had not depleted their annual deductibles (knee: OR 0.86 [0.79 – 0.94], hip: OR 0.90 [0.79 – 1.02]). This might be affected by the inclusion of physio/exercise therapy in basic health insurance in 2018. ConclusionWe have found a shift from hospitals to primary care in knee and hip osteoarthritis care. However, the use of physio/exercise therapy declined after changes in insurance coverage for patients that had not depleted their deductibles.

Health index scores and health insurance coverage across India: A state level spatiotemporal analysis

IntroductionSince the Government of India has decided to continue with the publicly funded health insurance (PFHI) strategy, it is now pertinent to attempt to determine the factors that drive health insurance coverage in India. The NITI (National Institute for Transforming India) Aayog (i.e. Commission) is the apex public policy think tank of the Government of India. The NITI Aayog assesses the health status of the states through its acclaimed health index consisting of 24 indicators for health outcomes, governance and infrastructure. All states and Union Territories (UTs) are ranked on the index. This study aims to assess associations between NITI Aayog health index scores and health insurance coverage across India through a state-level lens. MethodsHealth insurance coverage data has been extracted from the National Family Health Survey (NFHS) 4 and NFHS-5 data. NFHS-4 was conducted during 2015–16. NFHS-5 was interrupted by the COVID-19 pandemic and conducted in two phases from 2019 to 2021. This change in health insurance coverage is mapped to the NITI Aayog health index scores for the states and UTs. The NITI Aayog has classified states into two categories: Larger states and smaller states. Based on performance in health indices, NITI Aayog also classifies the states and UTs as Aspirants, Achievers and Front runners. Results and discussionThere is a positive linear relationship between the health index scores of front-runners (Pearson's r = 0.6037, p = 0.029) and the total insurance coverage. We observe poor linear relationship between the health index scores of achievers (Pearson's r = 0.2822, p = 0.498) and the total insurance coverage. There is no linear relationship between the NFHS-5 Total Insurance Coverage and the NITI Health Index Scores (Pearson's r = 0.2766, p = 0.125). Also, we observe a moderate positive linear relationship between the health index scores and the total insurance coverage among the Union Territories which is not statistically significant (Pearson's r = 0.4343, p = 0.465). A similar conclusion is made in the context of smaller states (Pearson's r = 0.3692, p = 0.368) and larger states (Pearson's r = 0.2103, p = 0.387). At the same time, we observe a decrease in insurance coverage across NFHS-4 and NFHS-5 in some states and UTs. Further research is needed to identify the determinants of these spatial changes across a span of five years, from a temporal lens.

Health insurance coverage patterns before and after a cancer diagnosis: Findings from adult patients with cancer in an integrated health system.

262 Background: Patients diagnosed with cancer experience intense medical care and high costs associated with the disease and its treatment. As a result, patients may consider changes to their health insurance coverage to adjust the medical benefits covered and/or the cost-sharing (e.g., annual maximum out-of-pocket [MOOP] limit) requirements. The purpose of this study was to assess the patterns of health insurance plan coverage patterns prior to and following a diagnosis of cancer among adult patients. Methods: Data from 13,237 patients aged ≥18, enrolled at Kaiser Permanente Northwest, diagnosed with cancer between Jan. 1, 2016–March 31, 2021 [index cancer], with ≥12 months of continuous health insurance coverage pre-cancer diagnosis were included. Patients enrolled in hospice prior to index cancer were excluded. Health insurance coverage outcomes included (1) coverage patterns (maintenance, interruption, termination, switch); (2) a composite of any coverage changes; and (3) cost-sharing patterns. Monthly health plan membership enrollment data was used to assess outcomes between two time periods: pre-diagnosis (12 months prior to index cancer) and post-diagnosis (12-18 months following index cancer). Patient sociodemographic, enrollment, health plan and clinical data were extracted from the electronic health record (EHR). Descriptive statistics were used to assess outcomes. Results: Approximately 40% of patients were ages 18-64, 54% were female and 9% were non-White. At index cancer diagnosis, 60% of patients had Medicare, 37% had a commercial plan and 3% had Medicaid. Among patients aged 18-64, 62% had any change in health insurance coverage between pre- to post-cancer diagnosis, including 41% who switched plans, 19% who terminated and 2% with an interruption. Among patients aged 65+, 50% of patients had any change in health insurance coverage, including 20% who switched plans, 30% who terminated and < 1% with an interruption. For those who switched plans between the pre- to post-diagnosis periods, the most common patterns included switching out of commercial plans (-11% points) and switching into either Medicare (+9% points) or Medicaid (+5% points). Among all patients, 14% changed to a higher cost-sharing plan (difference in mean individual, in-network MOOP limit: $938) and 10% changed to a lower cost-sharing plan (difference in mean individual, in-network MOOP limit: -$1701). Conclusions: Our novel findings provide valuable information about health insurance plan coverage patterns among adults diagnosed with cancer and suggest a large proportion of patients may undergo changes to their health insurance coverage. Future studies that assess the implications of health insurance changes on care access and cancer outcomes are warranted.

Changes in Cancer Mortality by Race and Ethnicity Following the Implementation of the Affordable Care Act in California.

Although Affordable Care Act (ACA) implementation has improved cancer outcomes, less is known about how much the improvement applies to different racial and ethnic populations. We examined changes in health insurance coverage and cancer-specific mortality rates by race/ethnicity pre- and post-ACA. We identified newly diagnosed breast (n = 117,738), colorectal (n = 38,334), and cervical cancer (n = 11,109) patients < 65 years in California 2007-2017. Hazard rate ratios (HRR) and 95% confidence intervals (CI) were calculated using multivariable Cox regression to estimate risk of cancer-specific death pre- (2007-2010) and post-ACA (2014-2017) and by race/ethnicity [American Indian/Alaska Natives (AIAN); Asian American; Hispanic; Native Hawaiian or Pacific Islander (NHPI); non-Hispanic Black (NHB); non-Hispanic white (NHW)]. Cancer-specific mortality from colorectal cancer was lower post-ACA among Hispanic (HRR = 0.82, 95% CI = 0.74 to 0.92), NHB (HRR = 0.69, 95% CI = 0.58 to 0.82), and NHW (HRR = 0.90; 95% CI = 0.84 to 0.97) but not Asian American (HRR = 0.95, 95% CI = 0.82 to 1.10) patients. We observed a lower risk of death from cervical cancer post-ACA among NHB women (HRR = 0.68, 95% CI = 0.47 to 0.99). No statistically significant differences in breast cancer-specific mortality were observed for any racial or ethnic group. Cancer-specific mortality decreased following ACA implementation for colorectal and cervical cancers for some racial and ethnic groups in California, suggesting Medicaid expansion is associated with reductions in health inequity.

Baseline Needs Assessment for a Hospital-Based Violence Intervention Program 1-Year Pilot

The objectives of the present study were to measure and describe the baseline participant needs of a hospital-based violence intervention 1-year pilot program, assess differences in expected hospital revenue based on changes in health insurance coverage resulting from program implementation and discuss the program’s limitations. Methods: Between September 2020 and September 2021 Encompass Omaha enrolled 36 participants. A content analysis of 1199 progress notes detailing points of contact with participants was performed to determine goal status. Goals were categorized and goal status was defined as met, in process, dropped, or participant refusal. Results: The most frequently identified needs were help obtaining short-term disability assistance or completing FMLA paperwork (86.11%), immediate financial aid (86.11%), legal aid (83.33%), access to food (83.3%), and navigating medical issues other than the primary reason for hospitalization (83.33%). Conclusions: Meeting the participants’ short-term needs is critical for maintaining their engagement in the long-term. Further, differences in expected hospital revenue for pilot participants compared with a control group were examined, and this analysis found a reduction in medical and facility costs for program participants. The pilot stage highlighted how complex the needs and treatment of victims of violence are. As the program grows and its staff become more knowledgeable about social work, treatment, and resource access processes, the program will continue to improve.

State-level changes in health insurance coverage and parental substance use-associated foster care entry

For many families whose children are placed in foster care, initial contact with the child welfare system occurs due to interactions with the healthcare system, particularly in the context of the opioid epidemic and increased attention to prenatal drug exposure. In the last decade, many previously uninsured families have gained Medicaid health coverage, which has implications for their access to healthcare services and visibility to mandatory reporters. Using administrative foster care case data from the Adoption and Foster Care Analysis and Reporting System Foster Care Files and health insurance data from the American Community Survey, this study analyzes the associations between state-level health insurance coverage and rates of foster care entry due to parental substance use between 2009 and 2019. State-level fixed effects models revealed that public, but not private, health insurance rates were positively associated with rates of foster care entry due to parental substance use. These results support the hypothesis that health insurance coverage may promote greater contact with mandatory reporters among low-income parents with substance use disorders. Furthermore, this study illustrates how healthcare policy may have unintended consequences for the child welfare system.

Evaluation of Changes in US Health Insurance Coverage for Individuals With Criminal Legal Involvement in Medicaid Expansion and Nonexpansion States, 2010 to 2017

This cross-sectional study compares changes in health insurance coverage from 2010 to 2017 for low-income US adults with criminal legal involvement in states that did and did not adopt the Medicaid expansion provision of the Affordable Care Act.

Associations of Medicaid Expansion With Access to Care, Severity, and Outcomes for Acute Ischemic Stroke.

Multiple states have not expanded Medicaid under the Affordable Care Act, resulting in higher uninsured rates in states with high stroke burdens. This study aimed to evaluate the association of Medicaid expansion with changes in health insurance coverage, severity of presentation, access to care, and outcomes among patients with acute ischemic stroke. A retrospective, difference-in-differences analysis of Get With The Guidelines-Stroke registry data. The study population comprised first-time ischemic stroke admissions from 2012 to 2018 for patients aged 19 to 64 in 45 states (27 that expanded Medicaid and 18 that did not). A probable low-income cohort was defined based on having Medicaid, no insurance/self-pay, or undocumented insurance. Outcomes analyzed were indicators of health insurance status, stroke severity, use of emergency services, time to acute care, in-hospital mortality, receipt of rehabilitation, discharge disposition, and level of disability. In the starting population (N=342 765), Medicaid-covered stroke admissions rose from 12.2% to 18.1% in expansion states and from 10.0% to only 10.6% in nonexpansion states, while uninsured admissions declined from 15.0% to 6.7% in expansion states and from 24.0% to 19.2% in nonexpansion states. In the low-income cohort (N=95 086; 28% of starting population), Medicaid expansion was associated with increased odds of discharge to a skilled nursing facility (adjusted odds ratio, 1.33 [95% CI, 1.12-1.59]) and transfer to any rehabilitation facility among those eligible (adjusted odds ratio, 1.24 [95% CI, 1.08-1.41]) and lower odds of discharge home (adjusted odds ratio, 0.89 [95% CI, 0.80-0.98]). Expansion was not associated with any other outcomes. Medicaid expansion is associated with fewer uninsured hospitalizations for acute ischemic stroke and increased rehabilitation at skilled nursing facilities. More targeted interventions may be needed to improve other stroke outcomes in the low-income US population. Future research should evaluate the impact of health care reform on primary stroke prevention.

Sick Pay and Absence from Work: Evidence from Flu Exposure

The system of sick-pay is critical for balancing the economic and health costs of infectious diseases. Surprisingly, most research on sick-pay reforms does not rely on variation in worker exposure to diseases when investigating absences from work. This paper studies the effects on absences from work of changes in health-insurance coverage of the first three days of sickness. We explore geographic variation in the prevalence of infectious diseases, primarily the seasonal flu, to provide variation in the need for sickness insurance. Estimates based on the Czech Structure of Earnings Survey imply that when sickness insurance is not available, total hours of work missed are not affected, but employees rely on paid and unpaid leave instead of sick-leave to stay home. The substitution effects are heterogenous across occupations and socio-demographic characteristics of employees, and suggest that workers do not spread infectious diseases at the workplace as a result of the absence of sickness insurance coverage in the first three days of sickness.

Addressing COVID-19 Using a Public Health Approach: Perspectives From the Cancer Prevention and Control Research Network

Addressing COVID-19 Using a Public Health Approach: Perspectives From the Cancer Prevention and Control Research Network

Insurance Churn and Inconsistent Access to Reproductive Health Care among Abortion Patients in Mississippi

Changes in health insurance coverage, or insurance churn, is common in the months surrounding pregnancy, but there has been limited study of how churn affects women's experiences with reproductive health care. We conducted in-depth interviews with women seeking abortion care in Mississippi in 2016. We coded interview transcripts relating to experiences accessing reproductive health care before pregnancy and organized the codes into themes. Of the 38 women interviewed, one-third were uninsured and half described recent changes in their health insurance. This contributed to inconsistent care, as women shifted from private clinicians while insured to health department clinics while uninsured. For several women, these shifts created barriers to contraceptive use and were closely related to their unintended pregnancy. Insurance churn and associated disruptions in contraceptive use were common among Mississippi women seeking abortion in this study. Policies should support women's reproductive autonomy by facilitating consistent coverage and reliable access to contraception.

The influence of the Affordable Care Act-Dependent Care Expansion on insurance coverage among young cancer survivors in California: an updated analysis.

To assess changes in health insurance coverage for young cancer patients pre- and post- the Affordable Care Act-Dependent Care Expansion (ACA-DCE) implementation in California. Further, we examined differences in insurance coverage by socioeconomic and race/ethnicity. Data were obtained from the California Cancer Registry and Medicaid enrollment files, from 2005 to 2014. We conducted difference-in-difference analyses among 7042 cancer patients aged 22-25 years ("intervention group") and 25,269 aged 26-34 years ("control group"). We also examined the independent and combined effects of race/ethnicity and neighborhood socioeconomic status (nSES) on insurance coverage. After the ACA-DCE implementation, we observed a 52.7% reduction in the proportion of uninsured and a 35.7% increase in the proportion of privately insured patients. There was also a 17.3% reduction in Medicaid at cancer diagnosis and a 27.5% reduction in discontinuous Medicaid enrollment. However, these benefits were limited to patients of non-Hispanic White, Hispanic and Asian/Pacific Islander race/ethnicity living in higher nSES, with no differences in insurance enrollment among young adults who lived in low nSES or those of Black race/ethnicity. The ACA-DCE broadened insurance coverage for young adults with cancer in California. Yet, only certain subgroups of patients have benefited from this policy.

Running the Numbers : Estimated Changes in Health Insurance Coverage of North Carolinians in the First Six Months of the COVID-19 Pandemic.

As the COVID-19 pandemic hit the United States and jurisdictions entered various levels of lockdown, the economic impacts across the country were catastrophic. This became most apparent through numbers of unemployment claims that had not been seen since the Great Depression [[1][1]]. Although many

The Affordable Care Act and Changes in Women's Health Insurance Coverage Before, During, and After Pregnancy in California.

Having health insurance is associated with improvements in health care access and use, health behaviors, and outcomes. We examined changes in health insurance coverage for California women before, during, and after pregnancy after implementation of the Affordable Care Act (ACA). We used data from the 2011-2017 California Maternal and Infant Health Assessment, an annual representative survey of women sampled from birth certificates (n = 47 487). We examined health insurance coverage at baseline before ACA implementation (2011-2013) and in each survey year from 2014 to 2017 for 3 periods (before, during, and after pregnancy). We calculated prevalence ratios to evaluate changes in health insurance coverage, adjusting for changes in demographic characteristics. Few women were uninsured during pregnancy before implementation of the ACA; therefore, analyses focused on health insurance before pregnancy and postpartum. Before ACA implementation, 24.4% of women reported being uninsured before pregnancy, which decreased to 10.1% in 2017. About 17% of women reported being uninsured postpartum before ACA implementation, and this percentage decreased to 7.5% in 2017. ACA implementation resulted in a >50% adjusted decline in the likelihood of being uninsured before pregnancy or postpartum, primarily because of substantial increases in Medicaid coverage. ACA implementation resulted in a dramatic reduction in mothers in California who were uninsured before and after pregnancy. Medicaid expansion played a major role in this improvement.

Changes in health insurance coverage, access to care, and health services utilization by sexual minority status in the United States, 2013‐2018

To examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013-2014 and 2017-2018. Data on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86181 heterosexuals aged 18-64years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys. Unadjusted and regression-adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression-adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics. Uninsurance declined for both sexual minority adults (5 percentage points, P<.05) and heterosexual adults (2.5 percentage points, P<.001) between 2013-2014 and 2017-2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017-2018 compared with 2013-2014. Low-income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults. Sexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.

Aging out of dependent coverage and the effects on the use of inpatient medical care.

We investigate the impact of losing health insurance coverage at age 26 due to aging out of the Affordable Care Act's dependent coverage on health insurance coverage rates and various indicators of inpatient medical care. We find that the probability of being covered under any type of health insurance plan decreases by 2.5-6.2 percentage points at age 26. However, the effects of this discrete change in health insurance coverage on inpatient medical care and related costs are insignificant.