Increase In Health Insurance Coverage Research Articles

The Impact of the Affordable Care Act in Puerto Rico

Abstract Was the Affordable Care Act (ACA) effective in the U.S. territories? This paper explores this question by examining the impact of the ACA’s dependent mandate and Medicaid expansion in Puerto Rico. The dependent mandate led to a 4.3 percentage point increase in health insurance coverage for Puerto Rican young adults due to increased employer-sponsored insurance coverage, and the Medicaid Expansion increased Medicaid coverage by 2.4 percentage points. The impact of both policies in Puerto Rico is smaller than in the mainland, highlighting the importance of considering how federal legislation affects territories with economic and health environments dissimilar to the mainland.

Health Insurance and Mental Health Treatment Use Among Adults With Criminal Legal Involvement After Medicaid Expansion.

Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.

Trends in cigarette use and health insurance coverage among US adults with mental health and substance use disorders.

To estimate recent trends in cigarette use and health insurance coverage for United States adults with and without mental health and substance use disorders (MH/SUD). Event study analysis of smoking and insurance coverage trends among US adults with and without MH/SUD using 2008-19 public use data from the National Survey on Drug Use and Health, an annual, cross-sectional survey. USA. A nationally representative sample of non-institutionalized respondents aged 18-64 years (n = 448762). Outcome variables were three measures of recent cigarette use and one measure of past-year health insurance coverage. We compared outcomes between people with and without MH/SUD (MH disorder: past-year mental illness, predicted from Kessler-6 and the World Health Organization-Disability Assessment Schedule impairment scale; SUD: met survey-based DSM-IV criteria for past-year alcohol, cannabis, cocaine or heroin use disorder) and over time. Comparing pooled data from 2008 to 2009 and from 2018 to 2019, current smoking rates of adults with MH/SUD decreased from 37.9 to 27.9% while current smoking rates of adults without MH/SUD decreased from 21.4 to 16.3%, a significant difference in decrease of 4.9 percentage points (pts)[95% confidence interval (CI) = 3.3-6.6 pts]. Daily smoking followed similar patterns (difference in decrease of 3.9 pts (95% CI = 2.3-5.4 pts). Recent smoking abstinence rates for adults with MH/SUD increased from 7.4 to 10.9%, while recent smoking abstinence rates for adults without MH/SUD increased from 9.6 to 12.0%, a difference in increase of 1.0 pts (95% CI = -3.0 to 0.9 pts). In 2018-19, 11% of net reductions in current smoking, 12% of net reductions in daily smoking and 12% of net increases in recent smoking abstinence coincided with greater gains in insurance coverage for adults with MH/SUD compared to those without MH/SUD. Improvements in smoking and abstinence outcomes for US adults with mental health and substance use disorders appear to be associated with increases in health insurance coverage.

The Effect of Health Insurance Coverage on Homeownership and Housing Prices: Evidence from the Medicaid Expansion

ObjectiveHomeownership as a way of wealth accumulation is important for low‐income people and the U.S. government has implemented policy to encourage homeownership among low‐income people. This article investigates the effects of health insurance coverage among low‐income people on homeownership and house prices.MethodsTo estimate the causal effects of health insurance coverage, we exploit the Medicaid expansion provisions of the Affordable Care Act as a source of exogenous variation in health insurance coverage and use it as an instrumental variable.ResultsUsing county‐level data from 2010 to 2018, this study finds that an increase in health insurance coverage among low‐income people results in an increase in homeownership rates and housing prices for bottom‐tier houses, and the results are robust.ConclusionOur study provides new evidence in supporting that higher shares of population with health insurance could increase both homeownership and house prices.

The 2020 US Presidential Election: Trump’s Wars on COVID-19, Health Insurance, and Trade

A common narrative is that COVID-19 cost Trump re-election. But, we do not find supporting evidence. Rather, our results highlight the political salience of the trade war and health insurance coverage in the 2020 US Presidential election. US trade war tariffs boosted Trump’s support and foreign retaliation hurt Trump. In particular, the pro-Trump effects of US trade war tariffs were crucial for Trump getting inside the recount thresholds in Georgia and Wisconsin. Even more important politically, voters abandoned Trump in counties with large increases in health insurance coverage since the Affordable Care Act, presumably fearing the roll-back of such expansion. Absent this anti-Trump effect, Trump would have been on the precipice of re-election by winning Georgia, Arizona, Nevada, and only losing Wisconsin by a few thousand votes. These effects cross political and racial lines. Thus, our results suggest a mechanism based around the local economic impact of Trump administration policies rather than a mechanism of political polarization.

Medicaid expansion, health insurance coverage, and cost barriers to care among low-income adults with asthma: the Adult Asthma Call-Back Survey

Objective To examine Medicaid expansion (ME) effects on health insurance coverage (HIC) and cost barriers to medical care among people with asthma. Method We analyzed 2012–2013 and 2015–2016 data from low-income adults with current asthma aged 18–64 years in the Behavioral Risk Factor Surveillance System Asthma Call-Back Survey (state-level telephone survey). We calculated weighted percentages and 95% confidence intervals from ME and non-ME jurisdictions (according to 2014 ME status). Outcomes were HIC and cost barriers to buying asthma medication (MED), seeing a health care provider for asthma (HCP), or any asthma care (AAC). Using SUDAAN, we performed survey-weighted difference-in-differences analyses, adjusting for demographics. Subgroup analyses were stratified by demographics. Results Our study population included 6445 participants from 25 states plus Puerto Rico. In 2015–2016 compared to 2012–2013, HIC was more common in ME jurisdictions (P < 0.001) but unchanged in non-ME jurisdictions. Adjusted difference-in-differences analyses showed ME was associated with a statistically significant 13.36 percentage-point increase in HIC (standard error = 0.053). Cost barriers to MED, HCP, and AAC did not change significantly for either group in descriptive and difference-in-differences analyses. In subgroup analyses, we noted variation in outcomes by demographics and 2014 ME status. Conclusions We found ME significantly affected HIC among low-income adults with asthma, but not cost barriers to asthma-related health care. Strategies to reduce cost barriers to asthma care could further improve health care access among low-income adults with asthma in ME jurisdictions.

Leveraging black-market street buprenorphine pricing to increase capacity to treat opioid addiction, 2010–2018

Increasing capacity to provide buprenorphine, a treatment for opioid addiction, can help mitigate the opioid epidemic in the United States. This study models black-market pricing of buprenorphine to better understand supply and demand for opioid addiction treatment. A mixed effects linear model was used to quantify the effect of county-level racial composition, health insurance coverage, and drug characteristics on price variation. From November 2010 to June 2018, there were 2481 submissions for street buprenorphine transactions in the StreetRx dataset. The mean price was $3.95/mg (SD = $23.12/mg). Price decreased 3.05% each year and was highest in the summer and spring. Brand name buprenorphine was on average 11.18% more expensive than generic buprenorphine. Buprenorphine/naloxone combinations were on average 19.75% less expensive than pure buprenorphine. Purchases in bulk were on average 10.51% cheaper than purchases not in bulk. Street buprenorphine in film form was on average 14.34% more expensive than in pill/tablet form. Buprenorphine street price was 17.12% higher in spring and 22.26% higher in summer compared to fall. For every percentage point increase in percent white, buprenorphine sold for 0.88% higher price. For every percentage point increase in health insurance coverage, street buprenorphine sold for 0.02% lower price. Findings demonstrate that geographic, demographic, and socioeconomic factors shape the diversion of opioid addiction treatment to the black-market. Buprenorphine street pricing can help estimate public need, gaps in care and emerging public health priorities.

Barriers to health care access among US adults with chronic conditions and co-occurring serious psychological distress between 2011-2015

Importance: Nearly 34 million adults – 17 percent of all American adults – have co-occurring mental and physical health conditions. However, the extent to which increased health insurance coverage has facilitated access to needed health care services among this population remains unclear. Objective: Prior research suggests that people with serious psychological distress (SPD) and cancer, heart disease, diabetes, asthma, or hypertension report worse access to care than people with the same physical conditions but no SPD. While the recent expansion in health insurance coverage was expected to improve access to care for people with SPD, access barriers that people with SPD report remain underexplored. Setting: Using the cross-sectional data from the National Health Interview Survey 2011-2015, we examined self-reported health care access barriers among adults (between ages 18 to 64) with SPD and co-occurring physical health conditions. Results: Our sample included 45,294 individuals with chronic conditions (heart disease, high blood pressure, diabetes, cancer, or asthma). Among them, 3,639 also had SPD. After controlling for demographic and socioeconomic factors, results of multivariate logistic regressions showed that individuals with co-occurring SPD and a physical health condition were significantly more likely to report that they had worse health insurance coverage compared to the prior year (OR=1.32, p<0.01), that doctor's office informed that they were not accepting new patients (OR=2.09, p<0.001), that the doctor's office stated they did not accept the particular health insurance they have (OR=1.98, p<0.001), that they couldn't get an appointment soon enough (OR=2.42, p<0.001), they had no transportation to get to the doctor (OR=3.23, p<0.001), and that overall they had trouble finding a doctor/provider (OR=2.12, p<0.001). Conclusions: Our results suggest that despite an increase in health insurance coverage between 2011 and 2015, barriers to access remain a significant concern for individuals with co-occurring SPD and physical health conditions.

THE EFFECTS OF THE AFFORDABLE CARE ACT ON HEALTH INSURANCE COVERAGE AND LABOR MARKET OUTCOMES

The Affordable Care Act (ACA) includes several provisions designed to expand insurance coverage that also alter the tie between employment and health insurance. In this paper, we exploit variation across geographic areas in the potential impact of the ACA to estimate its effect on health insurance coverage and labor market outcomes in the first two years after the implementation of its main features. Our measures of potential ACA impact come from pre-existing population shares of uninsured individuals within income groups that were targeted by Medicaid expansions and federal subsidies for private health insurance, interacted with each state’s Medicaid expansion status. Our findings indicate that the majority of the increase in health insurance coverage since 2013 is due to the ACA and that areas in which the potential Medicaid and exchange enrollments were higher saw substantially larger increases in coverage. While labor market outcomes in the aggregate were not significantly affected, our results indicate that labor force participation reductions in areas with higher potential exchange enrollment were offset by increases in labor force participation in areas with higher potential Medicaid enrollment

Mental Health Treatment Among Individuals Involved in the Criminal Justice System After Implementation of the Affordable Care Act

The objective of this study was to assess changes in health insurance coverage and mental health treatment among individuals with and without involvement in the criminal justice system after implementation of key provisions of the Affordable Care Act (ACA). Data from the National Survey on Drug Use and Health were used to assess changes in coverage, mental health treatment, and payer between 2011-2013 and 2014-2017 for nonelderly adults (ages 19 to 64) with and without criminal justice involvement in the past year who reported serious psychological distress. Multivariable logistic regression was used to obtain adjusted estimates. The weighted sample represented, on average, 2.0 million individuals with criminal justice involvement (total unweighted N=3,688) and 20.9 million without criminal justice involvement (total unweighted N=33,872) in each study year. Following implementation of the ACA's key provisions, health insurance coverage increased by 13.4 percentage points (95% CI=8.5-18.3) among individuals with past year criminal justice involvement and by 8.1 percentage points (95% CI=6.9-9.4) among those without. Receipt of any mental health treatment did not change significantly among individuals with criminal justice involvement (-3.4 percentage points [95% CI=-8.0 to 1.1]), whereas it increased significantly in the general population (2.2 percentage points [95% CI=0.4-3.9]). Despite an increase in health insurance coverage for people with criminal justice involvement, there was no increase in mental health treatment following implementation of the ACA's key provisions. Health insurance coverage is necessary, but not sufficient, to expand access to mental health treatment for individuals involved in the criminal justice system.

Abstract 3: Association of Medicaid Expansion with Cardiovascular Mortality - A Quasi-experimental Analysis

Background: Medicaid expansion under the Affordable Care Act (ACA) led to one of the largest gains in health insurance coverage for non-elderly adults in the US. However, its impact on health outcomes is unclear. We aimed to study whether trends in cardiovascular mortality for middle-aged adults differed between states that did and did not expand Medicaid. Methods: Using the CDC Wide-ranging Online Data for Epidemiologic Research mortality database, we obtained county-level, age-adjusted, cardiovascular mortality rates for all individuals 45 to 64 years of age from 2010 to 2016 for all states except Massachusetts and Wisconsin (due to non-ACA related Medicaid expansion in these two states). We used a differences-in-differences (DID) approach to measure differences in cardiovascular morality rates between states, based on Medicaid expansion status, before and after expansion. The DID estimator was adjusted for percentage of residents who were female, African-American, Hispanic, percentage of residents living in poverty, county unemployment rate, median household income, number of primary care providers per 100,000 residents, number of cardiologists per 100,000 residents, metropolitan vs. non-metropolitan county classification, and percentage of low-income residents with health insurance in 2010. Results: A total of 1960 counties were included. As of 2016, 29 states and DC had expanded Medicaid eligibility, while 19 states had not. Compared with counties in non-expansion states, counties in expansion states had a greater increase in health insurance coverage for low-income residents [19.8% (SD = 5.5) vs. 13.5% (SD = 3.9); p &lt;0.001]. Pre-expansion there were no significant differences in trends in mortality rates. Counties in expansion states had a significantly smaller increase in cardiovascular mortality rates [141.9 (95% CI 135.6, 148.3) to 142.0 (95% CI 135.5, 148.6) deaths per 100,000 residents per year] compared to counties in non-expansion states [176.1 (95% CI 169.3, 182.8) to 180.6 (95% CI 173.2, 188.0) deaths per 100,000 residents per year]. After accounting for differences in demographic and economic variables, counties in expansion states had 4.0 (95% CI 2.1, 6.0) fewer deaths per 100,000 residents per year from cardiovascular causes after expansion, compared to if they had followed the same trends as counties in non-expansion states. This effect was more prominent in non-metropolitan counties and in counties in the top 50 th percentile for residents living in poverty. Conclusion: Counties in Medicaid expansion states had a significantly smaller increase in cardiovascular mortality rates among non-elderly adults compared with counties in non-expansion states. Our findings suggest that Medicaid expansion was associated with a beneficial effect on cardiovascular mortality and may be an important consideration for states debating expansion of Medicaid eligibility.

The Effects of the Affordable Care Act on Workplace Absenteeism of Overweight and Obese Workers

In this paper, we examine whether the expansion of health insurance coverage brought on by the Patient Protection and Affordable Care Act of 2010 (ACA), led to a decline in absenteeism among overweight and obese individuals. We use data from the National Health Insurance Survey (NHIS) to compare absenteeism among overweight and obese workers to absenteeism among normal-weight workers before and after the ACA. Our results suggest that in the post-ACA period, the probability of being absent declined by about 1.3 (1.5) percentage points among obese (overweight) individuals. Disaggregated regressions suggest that the effect is significant among women, but not among men. Furthermore, our estimates (using a Tobit model) indicate that the obese (overweight) workers missed 0.33 (0.46) fewer days after the ACA. Again, the effect is concentrated among women. Our results show that improved health outcomes led to reduced absenteeism. Our results also show that there are no decline in absenteeism among elderly (age>=65) adults (who did not experience any increase in health insurance coverage as a result of the ACA), suggesting that the decline in absenteeism is indeed due to the expansion of health insurance coverage due to the ACA. Our estimates imply that the ACA reduced the cost associated with absenteeism by about $350 million per year.

Unlike Medical Spending, Medical Bills In Collections Decrease With Patients' Age.

Health policy is often designed to help protect patients' financial security. However, there is limited understanding of the role medical debt plays in household finances. We used credit report data on more than four million Americans to study the age profile of people whose medical bills were sent to a US collections agency in 2016. We found that, unlike health care use and spending, medical collections decreased substantially with age. The average size of medical debt decreased nearly 40percent from patients age twenty-seven to sixty-four, with increases in health insurance coverage and incomes likely playing important mediating roles. However, the frequency of medical collections-that is, the proportion of people with a collection by age-was less closely tied to insurance coverage rates. A potential explanation is that most medical collections were relatively modest in size, with more than half of them less than $600 annually. As a result, medical collections could still occur under typical insurance plans. We discuss how these results could inform policies targeting medical debt and insurance regulation, such as restrictions on age rating.

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X-Funded Facilities in 2016.

CONTEXTAs federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X–funded facilities under ACA guidelines is essential to understanding what is at stake.METHODSA nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X–funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi‐square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types.RESULTSMost clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign‐born clients were less likely than U.S.‐born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one‐quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out.CONCLUSIONCoverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.

Universal Health Insurance Coverage in Vietnam: A Stakeholder Analysis From Policy Proposal (1989) to Implementation (2014).

In 1989, health insurance (HI) was introduced in Vietnam and began to be implemented in 1992. There was limited progress until the 2014 Law on HI that was revised with the aim of universal health insurance coverage (UHIC) by 2020. This article explores stakeholder roles and positions from the initial introduction of HI to the implementation of the Master Plan accelerating UHIC. To better understand the influence of stakeholders in accelerating UHIC to achieve equity in health care. Using a qualitative study design, we conducted content analysis of HI-related documents and interviewed social security and health system key informants, government representatives, and community stakeholders to determine their positions and influence on UHIC. Our findings demonstrate different levels of support of stakeholders that influence in the HI formulation and implementation, from opposition when HI was first introduced in 1989 to collaboration of stakeholders from 2013 when the Master Plan for UHIC was implemented. Despite an initial failure to secure the support of the Parliament for a Law on HI, a subsequent series of alternative legislative strategies brought limited increases in HI coverage. With government financial subsidization, the involvement of multiple stakeholders, political commitment, and flexible working mechanisms among stakeholders have remained important, with an increasing recognition that HI is not only a technical aspect of the health system but also a broader socioeconomic and governance issue. The different levels of power and influence among stakeholders, together with their commercial and political interests and their different perceptions of HI, have influenced stakeholders' support or opposition to HI policies. Despite high-level policy support, stakeholders' positions may vary, depending on their perceptions of the policy implications. A shift in government stakeholder positions, especially at the provincial level, has been necessary to accelerate UHIC progress and build institutional capacity.

Trends in Disparities in Low-Income Children's Health Insurance Coverage and Access to Care by Family Immigration Status

ObjectiveTo examine time trends in disparities in low-income children's health insurance coverage and access to care by family immigration status. MethodsWe used data from the National Survey of Children's Health in 2003 to 2011–2012, including 83,612 children aged 0 to 17 years with family incomes <200% of the federal poverty level. We examined 3 immigration status categories: citizen children with nonimmigrant parents; citizen children with immigrant parents; and immigrant children. We used multivariable regression analyses to obtain adjusted trends in health insurance coverage and access to care. ResultsAll low-income children experienced gains in health insurance coverage and access to care from 2003 to 2011–2012, regardless of family immigration status. Relative to citizen children with nonimmigrant parents, citizen children with immigrant parents had a 5 percentage point greater increase in health insurance coverage (P = .06), a 9 percentage point greater increase in having a personal doctor or nurse (P < .01), and an 11 percentage point greater increase in having no unmet medical need (P < .01). Immigrant children had significantly lower health insurance coverage than other groups. However, the group had a 14 percentage point greater increase in having a personal doctor or nurse (P < .01) and a 26 percentage point greater increase in having no unmet medical need (P < .01) relative to citizen children with nonimmigrant parents. ConclusionsSome disparities in access to care related to family immigration status have lessened over time among children in low-income families, although large disparities still exist. Policy efforts are needed to ensure that children of immigrant parents and immigrant children are able to access health insurance and health care.

Health Insurance and Self-Employment

Previous studies have found that health insurance is an important component of workers’ labor market decisions. In this article, the author studies the effect of health insurance availability and price on the likelihood of self-employment by examining the Massachusetts (MA) health care reform enacted in 2006. A model of compensating differentials predicts that the effect of the MA reform on the likelihood of self-employment is theoretically ambiguous because different components of the reform should have opposing effects. For a sample from the Current Population Survey, the reform leads to a large and significant increase in health insurance coverage, and it increases the likelihood of self-employment by 0.71 percentage points, or an 8.4% increase from the pre-reform average in MA. The estimated positive effect on the likelihood of self-employment persists, though decreases, in the long run. The empirical evidence suggests that a part of the decline is coming from the opposing effects of various components of the reform.

Efficiency of health care delivery systems: effects of health insurance coverage

Health insurance expansions may increase the demand for care-creating incentives for health systems to increase input consumption. The possibility remains that added capacity and personnel will have little effect on health outcomes, decreasing the technical efficiency of health care delivery systems. We estimate that a 1 percentage point increase in health insurance coverage decreases the technical efficiency of health care delivery by 1.3 percentage points, translating into approximately 50 billion dollars in additional health expenditures. This finding uncovers a previously unexplored consequence of changes in health insurance on the supply side of health care markets suggesting one avenue through which health care costs growth may occur.

Change in health insurance coverage in Massachusetts and other New England States by perceived health status: potential impact of health reform.

We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health. We used 2003-2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform. The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states--from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs. On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.

Medical care costs in an extended inflation. A discussion of the development of the voluntary insurance mechanism, the medical care price index, inter-relationship of price indexes and quality changes, and the real cost of medical care.

Those who criticize the voluntary insurance mechanism in payment for health care because of rising costs of medical care prejudice the statement of an issue of considerable significance. There is much to be said for the hypothesis that the development of the voluntary insurance mechanism was brought about because of rising medical costs, not that the rise in medical costs was caused by the system developed. Despite such allegations by some critics 1 there is no evidence to support the position that the rise in medical care costs has been caused by the increase in health insurance coverage. 2 In fact, it has been pointed out that the average annual rate of increase in surgical fees was substantially greater for the period 1945 to 1950 than from 1950 to 1958, although the extent of health insurance coverage was greater during the latter period. 3 Such evidence does not support the