Health insurance and self‐assessed health: New evidence from Affordable Care Act repeal fear

Self‐assessed health is one of the most commonly used health measures by economists. However, changes in self‐assessed health are not always accompanied by changes in physical health as measured by clinical outcomes. This study provides suggestive evidence that this discrepancy arises because self‐assessed health is significantly influenced by psychological factors. Specifically, when the perceived risk of Affordable Care Act (ACA) repeal increased, as documented by Google Trends data, self‐assessed health declined among low‐income childless adults living in states that expanded Medicaid under the ACA.     

The impact of the Affordable Care Act on self‐employment

This paper estimates the impact of the implementation of the Affordable Care Act (ACA) in 2014 on the decision to be self‐employed. Using data from the Current Population Survey, we employ two identification strategies. Utilizing prereform variation in state nongroup health insurance market regulations, we find that the ACA did not increase self‐employment overall in states that lacked similar provisions in their nongroup markets prior to 2014. In specifications that utilize variation across individuals in characteristics that could make it harder for them to purchase insurance if they left their current employer, we also do not find that the ACA differentially increased self‐employment. However, in states that lacked the ACA nongroup market provisions, we do find a statistically significant increase in the second year of implementation (when individuals had more time to adjust behavior and the exchanges functioned properly) among individuals eligible for insurance subsidies, suggesting that a combination of time to adjust, low uncertainty and low insurance costs may be necessary for nongroup health insurance reforms to impact self‐employment.     

Access to health insurance and the use of inpatient medical care: Evidence from the Affordable Care Act young adult mandate

The Affordable Care Act of 2010 expanded coverage to young adults by allowing them to remain on their parent's private health insurance until they turn 26 years old. While there is evidence on insurance effects, we know very little about use of general or specific forms of medical care. We study the implications of the expansion on inpatient hospitalizations. Given the prevalence of mental health needs for young adults, we also specifically study mental health related inpatient care. We find evidence that compared to those aged 27–29 years, treated young adults aged 19–25 years increased their inpatient visits by 3.5 percent while mental illness visits increased 9.0 percent. The prevalence of uninsurance among hospitalized young adults decreased by 12.5 percent; however, it does not appear that the intensity of inpatient treatment changed despite the change in reimbursement composition of patients.     

Testing the myth of fee‐for‐service and overprovision in health care

Paying on the basis of fee‐for‐service (FFS) is often associated with a risk of overprovision. Policymakers are therefore increasingly looking to other payment schemes to ensure a more efficient delivery of health care. This study tests whether context plays a role for overprovision under FFS. Using a laboratory experiment involving medical students, we test the extent of overprovision under FFS when the subjects face different fee sizes, patient types, and market conditions. We observe that decreasing the fee size has an effect on overprovision under both market conditions. We also observe that patients who are harmed by excess treatment are at little risk of overprovision. Finally, when subjects face resource constraints but still have an incentive to overprovide high‐profit services, they hesitate to do so, implying that the presence of opportunity costs in terms of reduced benefits to other patients protects against overprovision. Thus, this study provides evidence that the risk of overprovision under FFS depends on fee sizes, patients' health profiles, and market conditions.     

A decade of health care access declines for adults holds implications for changes in the Affordable Care Act

The pending Supreme Court decision on the Affordable Care Act and the fall presidential election raise concerns about what would happen if the insurance expansion promised by the landmark health reform law were to be curtailed. This paper's analysis of national survey estimates found that access to health care and use of health services for adults ages 19-64--the primary targets of the Affordable Care Act--deteriorated between 2000 and 2010, particularly among those who were uninsured. More than half of uninsured US adults did not see a doctor in 2010, and only slightly more than a quarter of these adults were seen by a dentist. We also found that children--many of whom qualify for public coverage through Medicaid and the Children's Health Insurance Program--generally maintained or improved their access to care during the same period. This provides a reason for optimism about the ability of the coverage expansion in the Affordable Care Act to improve access for adults, but it suggests that eliminating the law or curtailing the coverage expansion could result in continued erosion of adults' access to care.     

Job mobility among parents of children with chronic health conditions: Early effects of the 2010 Affordable Care Act

We examine the effects of the 2010 Patient Protection and Affordable Care Act's (ACA) prohibition of preexisting conditions exclusions for children on job mobility among parents. We use a difference-in-difference approach, comparing pre-post policy changes in job mobility among privately-insured parents of children with chronic health conditions vs. privately-insured parents of healthy children. Data come from the 2004 and 2008 Survey of Income and Program Participation (SIPP). Among married fathers, the policy change is associated with about a 0.7 percentage point, or 35 percent increase, in the likelihood of leaving an employer voluntarily. We find no evidence that the policy change affected job mobility among married and unmarried mothers.     

Analysis & commentary: A new quality compass: hospital boards' increased role under the Affordable Care Act

The Affordable Care Act of 2010 promotes a clinically integrated, systems-based approach to health care. This means coordinating a patient's care over time and across all conditions, diseases, providers, and care settings. The aim is to achieve optimal results in terms of the overall quality of care as well as its efficiency, cost, safety, and timeliness. Hospital boards, which are legally accountable for the quality of the care their institutions provide, need to develop and implement effective quality oversight processes to achieve these objectives. Boards will have to focus less on the competence of individual providers and more on the functioning of the entire system of inpatient and outpatient care. We discuss the increased role of the boards in a systems-based approach to quality, and what steps they can take to meet the quality mandates of the Affordable Care Act.     

Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system

The Affordable Care Act, along with Medicaid expansions, offers the opportunity to redesign the nation's highly flawed mental health system. It promotes new programs and tools, such as health homes, interdisciplinary care teams, the broadening of the Medicaid Home and Community-Based Services option, co-location of physical health and behavioral services, and collaborative care. Provisions of the act offer extraordinary opportunities, for instance, to insure many more people, reimburse previously unreimbursed services, integrate care using new information technology tools and treatment teams, confront complex chronic comorbidities, and adopt underused evidence-based interventions. The Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation should work intensively with the states to implement these new programs and other arrangements and begin to fulfill the many unmet promises of community mental health care.     

The Affordable Care Act and Long-Term Care: Marginal Advancement on the Status Quo

The purpose of this analysis is to evaluate the sufficiency of the Long-Term Services and Supports (LTSS) provisions contained within the Patient Protection and Affordable Care Act (ACA). Beyond the ambitious but fatally flawed Community Living Assistance Services and Supports Act, the ACA’s LTSS changes represent only marginal advances over the status quo. Moreover, the impact of the ACA’s strategies varies with the extent to which the federal and state governments opt to invest in them, through funding, implementing, and enforcing the modest changes enacted. The ACA’s LTSS provisions, while welcome, are unlikely to result in the major changes necessary to meet both current and future demand for care.     

Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization

Context: Provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA) expand Medicaid to all individuals in families earning less than 133 percent of the federal poverty level (FPL) and make available subsidies to uninsured lower‐income Americans (133 to 400 percent of FPL) without access to employer‐based coverage to purchase insurance in new exchanges. Since primary care physicians typically serve as the point of entry into the health care delivery system, an adequate supply of them is critical to meeting the anticipated increase in demand for medical care resulting from the expansion of coverage. This article provides state‐level estimates of the anticipated increases in primary care utilization given the PPACA's provisions for expanded coverage. Methods: Using the Medical Expenditure Panel Survey, this article estimates a multivariate regression model of annual primary care utilization. Using the model estimates and state‐level information regarding the number of uninsured, it predicts, by state, the change in primary care visits expected from the expanded coverage. Finally, the article predicts the number of primary care physicians needed to accommodate this change in utilization. Findings: This expanded coverage is predicted to increase by 2019 the number of annual primary care visits between 15.07 million and 24.26 million. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase. Conclusions: The PPACA's health insurance expansion parameters are expected to significantly increase the use of primary care. Two strategies that policymakers may consider are creating stronger financial incentives to attract medical school students to primary care and changing the delivery of care in ways that lead to operational improvements, higher throughput, and better quality of care.