Effects of state reinsurance programs on health insurance exchange premiums and insurer participation

Objective

The aim of the study was to estimate the effect of the state-based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation.

Data Source

2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets.

Study Design

An event study difference-in-differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year-by-year effects following program implementation.

Data Collection/Extraction Methods

Not applicable.

Principal Findings

Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%–13%, 5%–19%, and 11%–17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation.

Conclusion

State-based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation.     

Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study

Objective. To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting. Kaiser Permanente–Northern California (KPNC), a prepaid integrated delivery system. Study Design. In a quasi‐experimental longitudinal study with concurrent controls, we estimated rates of ED visits, hospitalizations, ICU admissions, and deaths associated with higher ED copayments relative to no copayment, using Poisson random effects and proportional hazard models, controlling for patient characteristics. The study period began in January 1999; more than half of the population experienced an employer‐chosen increase in their ED copayment in January 2000. Data Collection/Extraction Methods. Using KPNC automated databases, the 2000 U.S. Census, and California state death certificates, we collected data on ED visits and unfavorable clinical events over a 36‐month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare insured health system members. Principal Findings. Among commercially insured subjects, ED visits decreased 12 percent with the $20–35 copayment (95 percent confidence interval [CI]: 11–13 percent), and 23 percent with the $50–100 copayment (95 percent CI: 23–24 percent) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not increase with copayments. Hospitalizations decreased 4 percent (95 percent CI: 2–6 percent) and 10 percent (95 percent CI: 7–13 percent) with ED copayments of $20–35 and $50–100, respectively, compared with no copayment. Among Medicare subjects, ED visits decreased by 4 percent (95 percent CI: 3–6 percent) with the $20–50 copayments compared with no copayment; unfavorable clinical events did not increase with copayments, e.g., hospitalizations were unchanged (95 percent CI: ?3 percent to +2 percent) with $20–50 ED copayments compared with no copayment. Conclusions. Relatively modest levels of patient cost‐sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events.     

Crowd-out and exposure effects of physical comorbidities on mental health care use: implications for racial-ethnic disparities in access

Objectives. In disparities models, researchers adjust for differences in “clinical need,” including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities. Data. Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n=11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care. Study Design. First, we tested a crowd‐out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates. Principal Findings. We found no evidence of a crowd‐out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black–white disparities and decreased Latino–white disparities. Conclusions. Positive exposure findings suggest that intensive follow‐up programs shown to reduce disparities in chronic‐care management may have additional indirect effects on reducing mental health care disparities.     

Impact of state Medicaid expansion on cross-sector health and social service networks: Evidence from a longitudinal cohort study

Objective

To examine the impact of state Medicaid expansion on the delivery of population health activities in cross-sector health and social services networks. Community networks are multisector, interorganizational networks that provide services ranging from the direct provision of individual social services to the implementation of population-level initiatives addressing community outcomes.

Data Sources

We used data measuring the composition of cross-sector population health networks 2006–2018 National Longitudinal Survey of Public Health Systems (NALSYS) linked with the Area Health Resource File.

Study Design

A difference-in-differences approach was used to examine the impact of expansion on organization engagement in population health activities and network structure.

Data Collection/Extraction Methods

Stratified random sampling of local public health jurisdictions in the United States. We restricted our data to jurisdictions serving populations of 100,000 or more and states that had NALSYS observations across all time periods, resulting in a final sample size of 667.

Principal Findings

Results from our adjusted difference-in-differences estimates indicated that Medicaid expansion was associated with a 2.3 percentage point increase in the density of population health networks (p < 0.10). Communities in states that expanded Medicaid experienced significant increases in the participation of local public health, local government, hospital, nonprofit, insurer, and K-12 schools. Of the organizations with significant increases in expansion communities, nonprofits (7.7 percentage points, p < 0.01), local public health agencies (6.5 percentage points, p < 0.01), hospitals (5.8 percentage points, p < 0.01), and local government agencies (6.0 percentage points, p < 0.05) had the largest gains.

Conclusions

Our study found increases in cross-sector participation in population health networks in states that expanded Medicaid compared with nonexpansion states, suggesting that additional coverage gains are associated with positive changes in population health network structure.     

The Boomers Are Coming: A Total Cost of Care Model of the Impact of Population Aging on Health Care Costs in the United States by Major Practice Category

Objective. To project the impact of population aging on total U.S. health care per capita costs from 2000 to 2050 and for the range of clinical areas defined by Major Practice Categories (MPCs).
Data Sources. Secondary data: HealthPartners health plan administrative data; U.S. Census Bureau population projections 2000–2050; and MEPS 2001 health care annual per capita costs.
Study Design. We calculate MPC-specific age and gender per capita cost rates using cross-sectional data for 2002–2003 and project U.S. changes by MPC due to aging from 2000 to 2050.
Data Collection Methods. HealthPartners data were grouped using purchased software. We developed and validated a method to include pharmacy costs for the uncovered.
Principal Findings. While total U.S. per capita costs due to aging from 2000 to 2050 are projected to increase 18 percent (0.3 percent annually), the impact by MPC ranges from a 55 percent increase in kidney disorders to a 12 percent decrease in pregnancy and infertility care. Over 80 percent of the increase in total per capita cost will result from just seven of the 22 total MPCs.
Conclusions. Understanding the differential impact of aging on costs at clinically specific levels is important for resource planning, to effectively address future medical needs of the aging U.S. population.     

中国老年人对医疗服务与长期照料服务的需要与利用研究——基于中国健康与养老追踪调查的实证分析

目的 了解中国老年人对医疗和长期照料服务的需要与利用情况;分析对医养结合型服务的潜在需要;为促进我国医养结合型服务的发展提供参考依据。方法 利用中国健康与养老追踪调查的数据,分析60岁以上老年人对医疗服务与长期照料服务的需要与利用情况以及对医养结合型服务的潜在需要。结果 全体老年人中,有14.01%和7.21%的老人存在应就诊而未就诊和应住院未住院的情况;在失能老人中,有39.44%的比例未获得照料;在潜在存在医养结合型服务需要的老人中,仅有37.46%的老人两种需要同时得到满足。结论 老年人对医疗与长期照料服务的需要较大并且同时存在,但对它们的利用并不充分。建议政府推进医养结合型服务的发展,在促进医养结合型服务供给的同时提高对老年人的保障力度。     

政策工具视角下我国医养结合政策文本研究

本文从政策工具视角对我国医养结合政策文本进行分析,揭示现有政策工具在政策过程中应用的特点与盲点,并提出相应的政策建议,为完善医养结合政策体系提供借鉴。方法:基于政策工具和政策过程两个维度构建二维分析框架,采用内容分析法,对83项医养结合政策文本、919个政策条文进行分析。结果:政策工具结构不均衡,供给型政策工具占53.86%、需求型政策工具占5.66%、环境型政策工具占40.48%。政策过程不协调,议程设置占12.95%、政策制定占66.27%、政策执行占17.08%、政策评估占3.7%。结论:优化医养结合政策工具结构;统筹医养结合政策过程;健全医养结合政策系统,不断提升医养结合政策工具科学化水平。     

医养结合的资源、服务与产出的关系实证研究:从居家老年人的视角

目的:本研究从使用者视角对医养结合的资源、服务与阶段性产出进行关系检验,评价样本城市的医养结合工作效果。方法:基于系统理论搭建医养结合资源、服务与产出的关系路径,利用江苏省某市的分层抽样数据进行路径拟合,开展多个模型的对比分析。结果:服务内容与医养服务、医养服务与医养产出之间存在显著正相关关系,服务方式与医养服务之间、医养资源与医养产出之间则不存在显著相关关系。结论:"服务方式升级"和"人力资源及其整合"在应对人口高龄化问题方面将具有积极的意义。