State Health Insurance Exchanges Research Articles

Abstract A112: A longitudinal evaluation of repeat colorectal cancer screening in a Federally Qualified Health Center (FQHC)

Abstract Background: Colorectal cancer (CRC) can be detected early or prevented through screening at recommended intervals. Fecal immunochemical testing (FIT), an inexpensive stool-based screening test, is the primary screening modality in low-resource health care settings, including Federally Qualified Health Centers (FQHCs). However, to maximize its life saving benefit, FIT screening must be completed annually (repeat screening), per guidelines. In FQHCs, only about 40% of eligible patients are up-to-date on CRC screening at a given time. Less is known about completion of repeat FIT over time in this setting. Therefore, UCLA partnered with Northeast Valley Health Corporation (NEVHC), a large multi-site FQHC serving predominantly low-income Latinos, to assess repeat FIT rates and factors that contribute to repeat FIT over a 5-year follow-up period. Methods: We performed a retrospective cohort study among NEVHC patients who completed a FIT test in 2013 and examined CRC screening completion over the subsequent 5 years (2014-2018). The study was conducted in eight comprehensive primary care sites at NEVHC. Our cohort included patients ages 50-70 years with a normal index FIT in 2013 and who were active NEVHC patients during the subsequent 5-year follow-up period. Using electronic medical record and administrative data, we identified that only one patient completed five rounds of screening at yearly intervals, as recommended, and thus calculated “repeat FIT” rate as the proportion of patients who completed at least 3 total FIT tests or a colonoscopy (i.e., index FIT and 2 additional FIT tests or colonoscopy) over the 6-year study period (2013-2018). We also performed bivariate analyses to evaluate factors associated with repeat FIT completion. Results: Among the 771 patients included in our sample, the average age at index FIT was 57 years. The majority of patients were Latino (83%, n=638) and spoke Spanish as their primary language (76%, n=588), and 43% (n=330) were insured through Medicaid, Medicare, California’s state health insurance exchange, or other private insurance. Overall, 61% (n=471) of our sample completed at least 3 total FIT tests or colonoscopy over the 6-year study period. There were significant differences in repeat FIT rates across the eight primary care clinics, ranging from 34% to 72%; the highest volume clinic had the highest repeat FIT rate. Significantly higher rates of repeat FIT were also observed among patients with frequent encounters and who were Latino vs. non-Latino (65% vs. 42%), Spanish-speaking vs. not (68% vs. 40%), uninsured or self-pay vs. publicly or privately insured (70% vs. 49%); all p<0.05.Conclusions. Findings suggest significant patient and clinic variation in completion of repeat FIT testing among active patients engaged in care. These results support the need for interventions to improve recurrent, guideline-concordant FIT screening in low-resource clinical settings that deliver essential cancer screenings to medically underserved populations. Citation Format: Narissa J. Nonzee, Beth A. Glenn, Debra Rosen, Alison K. Herrmann, Folasade P. May, L. Cindy Chang, Catherine Crespi, Alicia Lwin, Christine Park, Analissa Avila, Roshan Bastani. A longitudinal evaluation of repeat colorectal cancer screening in a Federally Qualified Health Center (FQHC) [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A112.

The Affordable Care Act and Polarization in the United States

We argue that partisan polarization in public support of the Affordable Care Act (ACA) is affected not only by policy design but also by which party makes those decisions. Using an innovative dataset that measures state-level quarterly ACA support from 2009 through the start of the 2016 presidential election, we find that opinions toward the ACA are less polarized in states with misaligned partisan environments where Republican governors support Medicaid expansion. We also find evidence that Republican opposition intensifies when a Democratic governor supports expansion. We do not find consistent evidence of such patterns for governors’ positions on state health insurance exchanges. Our research sheds light on a key aspect of how health policy preferences respond to shifting political contexts in a polarized, federated polity.

The Patient Protection and Affordable Care Act (PPACA)

The Patient Protection and Affordable Care Act (PPACA) were signed into law on March 23, 2010. This signing into law ushered a new era in the United States healthcare. The law incorporates elements such as state health insurance Exchanges, individual and employer responsibility provisions, group subsidies to individuals, small employers and Medicaid expansion [1].

Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act.

Millions of adults have gained insurance through the Affordable Care Act (ACA). However, disparities in access to care persist. This study examined differences in access to primary and specialty care among patients insured by private individual market insurance plans (both on-exchange and off-exchange) and Medicaid compared with those with employer-sponsored insurance. Using data from the 2014 and 2015 California Health Interview Survey, logistic regression analyses were used to calculate the odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor's appointment in a timely manner, with insurance type serving as the independent variable. Interaction terms examined if the expiration of the ACA's optional Medicaid primary care fee increase in 2014 modified any of these associations. Findings showed poorer access to providers among those insured through Medicaid and the individual market (whether purchased through the state's health insurance exchange or off-exchange) relative to employer-based insurance. Poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. In addition, findings showed that reduction of Medicaid fees coincided with reduced ability to see primary care providers. However, a similar trend was seen among those with employer-based coverage, which suggests that this change may not be attributable to reductions in Medicaid fees. Despite ACA-related gains in insurance coverage, those with on-exchange and off-exchange individual private insurance plans and Medicaid encounter more barriers to care than those with employer-based insurance.

Benefit requirements for substance use disorder treatment in state health insurance exchanges

ABSTRACTBackground: Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations. Objective: How states regulate SUD treatment benefits offered by QHPs has implications for the accessibility and quality of care. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls. Methods: Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey. Results: States varied widely in regulations on QHPs' administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used. Conclusion: Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.

Access To Mental Health Care Increased But Not For Substance Use, While Disparities Remain.

We assessed whether early implementation of Affordable Care Act (ACA) Medicaid expansion and state health insurance exchanges increased access to mental health and substance use treatment among those in need and whether these changes differed by racial/ethnic group. We found that mental health treatment rates increased significantly but found no evidence of a reduction in the wide racial/ethnic disparities in mental health treatment that preceded ACA expansion from 2005 to 2013.

The Work Experiences of Community Health Professionals: Implications for the Continued Rollout of the Affordable Care Act.

State health reform (Patient Protection and Affordable Care Act [ACA]) policies may impact the work experiences of community health professionals. We examine the extent to which community health professional work experiences differ depending on state Medicaid expansion and health insurance exchange policies. Public Health Workforce Interests and Needs Survey (PH WINS) (2014) responses from public health nurses, community health workers, health educators, and other public health professionals were merged with state ACA Medicaid expansion and health insurance exchange operations data. We used multivariate regression to examine the extent to which community health professionals in states without Medicaid expansion, or expansion states without a state-run health insurance exchange, reported lower-quality work experiences and less leadership support than did community health professionals working in Medicaid expansion states with state-run health insurance exchanges, controlling for worker characteristics. Local and state health departments (SHD) in 37 states. 10,246 state health department and 6450 local health department (LHD) workers. Work satisfaction (job, organization, pay, and job security), quality of work experiences, leadership support, and impact of the ACA on work. In adjusted analyses, LHD community health professionals in states without Medicaid expansion reported worse experiences of leadership support (β = -9.83; P < .05). LHD community health professionals in Medicaid expansion states without state-run health insurance exchange operations reported lower-quality work experiences (β = -13.06; P < .01), less leadership support (β = -11.52; P < .001), and perceived greater impacts of the ACA on their work (β = 9.18; P < .001) than did LHD community health professionals in expansion states with state-run health insurance exchanges. Less state control over health insurance exchange operations or state inaction with respect to Medicaid expansion may negatively impact LHD community health professional work experiences and perceptions of leadership support.

The Scrapping of Maryland’s State Health Insurance Exchange Marketplace

Just like healthcare.gov, the Maryland Health Connection (MHC) website crashed within the first few minutes of operation on October 1, 2013 (Davis and Flaherty 2014. Maryland officials were warned for a year of problems with online health-insurance site - The Washington post). Upon receipt of the first million dollar grant in 2010, the MHC’s governing body, the Maryland Health Benefit Exchange (MHBE) Board of Governors, and Maryland’s political leadership immediately began trumpeting their early adoption prowess. All that bravado makes this week’s acknowledgement of failure much harder to swallow. Noridian and EngagePoint, the primary contractors tasked with building the technological support infrastructure behind the failed MHC, have been fired. Deloitte is now formally in charge of bringing their successful state health insurance exchange software from the state of Connecticut and implementing it on behalf of the state of Maryland. The MHC project suffered from five major project management mistakes that directly contributed to the rampant waste and failure. The most detrimental of these mistakes was the MHBE’s outsourcing of a project that they did not understand.

Impact of the Affordable Care Act on health insurance access, coverage, and cost for refugees resettled in the USA

Abstract Background Refugees arriving in the USA are a vulnerable population with limited access to health insurance. The Affordable Care Act (ACA) has been heralded as an opportunity to reduce health-care disparities by improving access to health insurance. However there is substantial between-state variation with respect to enactment of Medicaid expansion and implementation of health-care insurance exchanges. We sought to describe the relation between 2012 refugee resettlement patterns and health-care insurance improvements created by the ACA. Methods We conducted a cross-sectional analysis of 2012 refugee resettlement data from all 50 states and the District of Columbia. We obtained data from the Office of Refugee Resettlement, the Kaiser Family Foundation, and the US Government health insurance website healthcare.gov. We compared resettlement data for states that have expanded Medicaid and implemented Health Insurance Exchange schemes and those that have not. We used the Wilcoxon rank sum test to investigate whether there was a relation between the price of insurance policies in each state and refugee resettlement rates there. Findings In 2012, 58 238 refugees from 85 countries were resettled in the USA. 32 389 refugees were resettled to 27 states that expanded Medicaid coverage under the ACA (median 555, range 0–5173 refugees per state). This rate did not differ from that for the 25 849 refugees who were resettled to 24 states not expanding Medicaid coverage (median 775 [0–5293]; p=0·7341). The median number of refugees resettled to the 17 states creating health insurance exchanges was 817 (1–5173), which was no higher than the median number of refugees resettled to the 34 states using the federal insurance exchange (601 [0–5923]; p=0·4906). The median monthly premium for a bronze health insurance plan did not differ between states with insurance exchanges ($232) and states with only the federal exchange ($264; p=0·1365). Interpretation In 2012, more refugees were resettled to states that have not expanded Medicaid or created state health insurance exchanges. Because many states have small or no refugee resettlement programmes, the difference in distribution of resettlement based on state insurance policies does not reach statistical significance. Future research should explore the effect of these differences in state policies on refugee health outcomes. Policymakers should consider between-state variation in access to insurance when devising refugee resettlement strategies. Funding None.

Medicaid Expansion and the use of Account-based Health Plans

Objectives: U.S. Medicaid expansion has added over 11 Million new enrollees since 2010 and U.S. states are attempting to integrate the increased population as well as addressing fiscal constraints. Account based plans (such as Health Savings Accounts) have been successfully used to control utilization while providing enrollee flexibility. We suggest that a portion of the 55 million Medicaid beneficiary population can be enrolled in account based plans and assist state and federal Health Insurance Exchanges with the ‘churn’ that occurs between the two systems while controlling costs. Methods: We use publicly available per capita Medicaid spending in each state to estimate the population that could be enrolled in an account based plan and apply factors from previous private market research in estimating the reduction in utilization trend and spend for the selected population. Results: We find that using conservative enrollment and utilization trend assumptions that states could collectively see a reduction in spend of over $800 million to over $1 billion in a fiscal year. Conclusions: States can enroll select Medicaid populations that could benefit from having a potentially seamless product that would allow individuals to transition between Medicaid plans and state and federal Health Insurance Exchange products while reducing utilization and spend.

Young Adult's Perspectives on Being Uninsured and Implications for Health Reform

Young adults between the ages of 18-34 are most likely to lack health insurance in the United States. The Affordable Care Act (ACA), a federal statute signed into law in 2010, contains provisions specific to increasing access to health insurance for young adults including the provision that persons under 26 can stay on their parents’ insurance. While the reasons for uninsurance among young adults have been documented, how they operate and are perceived on an individual level have not been explored in great detail. Further, it is poorly understood how the ACA policies and the state health insurance exchanges can serve young adults. Thus, we interviewed uninsured young adults aged 18-35 in northeastern Minnesota and northwestern Wisconsin and used inductive thematic analysis to explore these issues. Findings suggest that young adults don’t feel at risk for health problems and therefore have low levels of health insurance literacy and place little value on health insurance. Multiple barriers to health insurance coverage, including the provision about staying on a parent’s policy, persist despite the ACA. Our findings also suggest valuable lessons for state health insurance exchanges on how to better serve this population.

Medicaid Politics: Federalism, Policy Durability, and Health Reform

Medicaid Politics: Federalism, Policy Durability, and Health Reform

Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage.

Beginning in 2014, federal guidelines for health plans sold to people in the individual market allow insurers to charge tobacco users up to 50 percent more for premiums, compared to nonusers. We examined variations in tobacco surcharges for plans offered through the state and federal health insurance exchanges, or Marketplaces. The plan with the median surcharge had only 10 percent higher premiums for tobacco users compared to nonusers, and nine in ten plans charged a lower surcharge than allowed. Even with such lower-than-allowed surcharges, tobacco users lacked affordable coverage-defined as access to at least one plan with premiums of less than 8 percent of income after subsidies-in more states than did nonusers. Higher premiums could encourage tobacco users to opt out of coverage. Our results also suggest that the variation in tobacco surcharges may result in the sorting of tobacco users and nonusers into different plans.

Diabetes, obesity, and the Affordable Care Act

Before President Barack Obama’s landmark health law took eff ect, obtaining aff ordable health insurance could be diffi cult for Americans with diabetes or obesity, if not impossible. Insurers that didn’t turn diabetic patients away could charge higher rates because these individuals had a preexisting health problem, or they could exclude coverage for certain treatments for diabetes or other chronic disorders. Companies could limit reimbursable medical expenses or even cancel coverage as medical needs increased. Now such practices are prohibited under the Patient Protection and Aff ordable Care Act (ACA) for insurance policies purchased by individuals and small businesses through the new online health insurance exchanges, or for employment-based policies. “People with diabetes, and all Americans, can no longer be denied access to the health insurance they need, will not have their insurance run out when they need it most, and cannot be discriminated against based on pre-existing conditions, such as diabetes,” said Krista Maier, the American Diabetes Association’s associate director for public policy. And people with diabetes or obesity might be among those who best understand what the new rules mean. Average medical expenses for an American with diabetes are more than double the cost for someone without the disease, according to the fi rst “Diabetes Report Card” published in 2012 by the US Centers for Disease Control and Prevention, which the ACA requires every 2 years to assess data on diabetes and prediabetes, preventive care practices, risk factors, quality of care, and diabetes outcomes. “Adequate and aff ordable health insurance is important for people with diabetes to help them access the supplies, medications, education, and health care to manage their diabetes and prevent its devastating complications, including blindness, amputation, heart disease, and kidney failure”, said Maier . The law provides federal subsidies to individuals to purchase policies from the online health insurance exchanges to help those who can’t aff ord insurance. And it expands Medicaid, the federal-state partnership programme of health insurance for low-income families. However, after the Supreme Court ruled that the expansion was not mandatory, 24 states have opted out. The 8 million people who enrolled in health insurance exchange policies in this fi rst year exceeded the Obama Administration’s goal by 2 million. Another 3 million gained coverage through the Medicaid expansion. The American Diabetes Association hopes more states will expand Medicaid “to ensure hard-working, low-income families, including those aff ected by diabetes, who need access to aff ordable health-care coverage, no longer have to worry about aff ording the care they need to manage their disease”, said Maier. In addition to dramatically changing how health insurance is bought and sold in the USA, the ACA also specifi es what it should cover. The law lists ten “essential health benefi ts” most policies must include and, of those, prescription drug coverage, preventive services, and chronic disease management are of most interest to people with diabetes or obesity. For example, preventive health services recommended by the US Preventive Services Task Force must be covered by most insurance policies at no cost to patients. The free services include type 2 diabetes screening, dietary and weight-loss counselling, and blood pressure checks. The ACA also requires Medicare, the federal health programme for 52 million older or disabled Americans, to off er similar preventive health services with no cost-sharing to patients. And state-run Medicaid programmes, for low-income families, that also do so will receive additional federal reimbursement. The emphasis on prevention in the ACA is particularly important for people with obesity, who can get insurance coverage for intensive behavioural therapy, and dietary counselling with no copayments. “The good news is people have better access to health insurance at a better price”, said Ted Kyle, an advocacy advisor for the Obesity Society, an organisation for scientists, physicians, nurses, and other professionals. “The bad news is that change is slow, and some of the bad habits related to how health plans deal with obesity are hanging on”, he said. Coverage for bariatric surgery for severe obesity is optional in many state health insurance exchanges. And, although these plans have to provide drug coverage, they don’t have to cover medications for obesity. By contrast, Kyle said the federal government recently told insurance carriers off ering coverage for federal employees that, although coverage for weight-loss drugs for obesity is not required, such drugs cannot be excluded solely because insurers consider obesity a lifestyle disorder or regard obesity treatment to be cosmetic. But health insurance plans sold on the exchanges can still deny drug coverage for these reasons, he said. The Obesity Society and other organisations have urged federal offi cials to extend the restriction to health insurance exchange plans.

Can Consumers Make Affordable Care Affordable? The Value of Choice Architecture

Tens of millions of people are currently choosing health coverage on a state or federal health insurance exchange as part of the Patient Protection and Affordable Care Act. We examine how well people make these choices, how well they think they do, and what can be done to improve these choices. We conducted 6 experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. Our results suggest there is significant room for improvement. Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do not improve performance, and decision-makers do not realize that they are performing poorly. However, performance can be improved quite markedly by providing calculation aids, and by choosing a “smart” default. Implementing these psychologically based principles could save purchasers of policies and taxpayers approximately 10 billion dollars every year.

Paying for value: What's next?

With the Supreme Court's upholding of the Affordable Healthcare Act (ACA), all eyes have now turned to the industry to see whether this law can truly improve the health status of our nation. In 2014, major changes are expected to occur, including state health insurance exchanges and Medicaid expansion. Thus, many observers have remarked that the ACA's focus is more about improving access to health care, as opposed to the delivery of that care. By providing more Americans with access to a healthcare system that rewards volume instead of quality or value, there are valid concerns the ACA may exacerbate the problem of rapid cost growth. In response to the challenge of paying for public programs and private health insurance, several initiatives have already emerged to improve value in our health care delivery system. We believe that bundled payments are a critical piece of the solution that can provide a framework for high-value providers to be awarded for quality and cost efficiency, rather than being penalized as a FFS system would do. Our payment system is primarily fee-for-service (FFS), which is designed to reward more volume and has been effective in driving more services. While FFS is in many ways dysfunctional, it is familiar to providers, employers and members. It is well supported by current claims systems and processes and does not require providers to assume any degree of risk. Therefore, while we think these new paradigms are superior in many ways, it is likely that FFS will exist for some time to come.

Building a Relationship between Medicaid, the Exchange and the Individual Insurance Market

The alignment of Medicaid and State Health Insurance Exchange (Exchange) policy and practice is a basic tenet of the Patient Protection and Affordable Care Act (ACA). Through both legislative provisions and implementing regulations, the ACA addresses this relationship.1 At the same time, the federal framework provides states with considerable discretion to flesh out the fuller dimensions of system interaction.Even as the federal framework is still evolving, this report examines the practical and conceptual factors that underlie the federal/state relationship. It describes dimensions of collaboration that could help establish a seamless continuum of coverage for those who may move between eligibility for Medicaid or for tax subsidies in the Exchange. Proposed regulations outlining eligibility determination obligations of state Medicaid agencies and Exchanges have been issued. Still to appear are regulations defining essential health benefits, but sub-regulatory policies were issued in a special federal bulletin on December 16, 2011. These will define the scope of essential health benefits to be offered by Qualified Health Plans (QHPs)2, which in turn also will define the coverage obligations of Medicaid “benchmark” coverage for newly eligible persons.

JHPPL Workshop on Medicaid Fiscal and Governance Issues: Objectives and Themes

At a November 2012 workshop, state health policy officials, other Medicaid and insurance exchange practitioners, and health policy researchers discussed issues surrounding the implementation and sustainability of Medicaid expansion and insurance exchange coordination under the Patient Protection and Affordable Care Act (PPACA). Foremost were concerns about (1) intergovernmental relations (states experiencing uncertain information, lack of coordination among federal agencies, and limited resources to take on new responsibilities under the PPACA), and (2) policy design (new issues such as Medicaid exchange coordination on top of preexisting Medicaid challenges). JHPPL has proposed the creation of a research network to develop policy options and share strategies and best practices.

Structure of the Physical Therapy Benefit in a Typical Blue Cross Blue Shield Preferred Provider Organization Plan Available in the Individual Insurance Market in 2011

The Affordable Care Act of 2010 establishes American Health Benefit Exchanges. The benefit design of insurance plans in state health insurance exchanges will be based on the structure of existing small-employer-sponsored plans. The purpose of this study was to describe the structure of the physical therapy benefit in a typical Blue Cross Blue Shield (BCBS) preferred provider organization (PPO) health insurance plan available in the individual insurance market in 2011. A cross-sectional survey design was used. The physical therapy benefit within 39 BCBS PPO plans in 2011 was studied for a standard consumer with a standard budget. First, whether physical therapy was a benefit in the plan was determined. If so, then the structure of the benefit was described in terms of whether the physical therapy benefit was a stand-alone benefit or part of a combined-discipline benefit and whether a visit or financial limit was placed on the physical therapy benefit. Physical therapy was included in all BCBS plans that were studied. Ninety-three percent of plans combined physical therapy with other disciplines. Two thirds of plans placed a limit on the number of visits covered. The results of the study are limited to 1 standard consumer, 1 association of insurance companies, 1 form of insurance (a PPO), and 1 PPO plan in each of the 39 states that were studied. Physical therapy is a covered benefit in a typical BCBS PPO health insurance plan. Physical therapy most often is combined with other therapy disciplines, and the number of covered visits is limited in two thirds of plans.

Social Work and Implementation of the Affordable Care Act

The Affordable Care Act (ACA) (full title: The Patient Protection and Affordable Care Act) (P.L. 111-148) will generate sweeping changes in the financing, organization, and accessibility of health and social services in the United States. The expansion of Medicaid and the establishment of state health insurance exchanges (HIEs) will vastly expand insurance access in the United States, with an estimated 30 million Americans gaining coverage (Banthin et al., 2012). The emphasis on integrated models of care, including patient-centered medical homes and accountable care organizations, introduces new opportunities to improve care coordination, reduce unnecessary service use, and make health care more cost-effective. Realizing these changes relies on the work of many health care professions. In this editorial, we make a case for how the social work profession can forge a leadership role in implementing this historic legislation. Because the ACA is so bold and ambitious, it is important to consider how the unique skills and knowledge bases of social work and other health care professions align with its objectives and goals. An integrated approach is needed to maximize the ACA's potential to improve the health of the population.