Health Care Reform and Young Adults' Access to Sexual Health Care: An Exploration of Potential Confidentiality Implications of the Affordable Care Act

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent’s private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences.Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues.Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.ON MARCH 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, effecting the most significant change to the US health care system since the creation of the Medicare and Medicaid programs in 1965.1 All components of the health sector are affected: the legislation includes expansions of public coverage, new subsidies for private coverage, health insurance exchanges, insurance coverage requirements and mandates, and strategies to increase the efficiency of health care delivery and rein in health care costs. Such sweeping reforms bring a host of intended changes and potential unforeseen ramifications. One provision of the ACA expands access to dependent coverage for young adults on their parent’s health insurance up to age 26 years, regardless of marital, employment, or educational status, effective September 2010. Previously, the maximum age varied by state, with eligibility for dependent coverage often linked to factors such as educational enrollment status. The government Web site describes the intended benefits of this provision: “By allowing children to stay on their parent''s plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.”2Young adults aged 19 to 26 years have the highest uninsured rate of any age group in the country; 30% were without coverage in 2009.3 The high rate reflects many contributing factors. Young adults are more likely than other working-aged adults to be unemployed; if working, they are more likely to be newly employed, employed in entry-level jobs, and working in part-time positions without access to employer coverage. Furthermore, most young adults do not meet the traditional categorical eligibility requirements for the Medicaid program—the parent of a child younger than 19 years or an aged or disabled individual—and so young adults, even those with very low incomes, seldom qualify for public coverage. The subsequent low levels of insurance result in limited access to care and high levels of unmet need for care.4By expanding access to health insurance coverage, the ACA addresses two Healthy People 2020 goals5: attaining a higher proportion of individuals with insurance and reducing the proportion of individuals who are unable to obtain or who delay obtaining necessary medical care. This provision of the ACA has already shown significant success in expanding health insurance coverage for young adults. The percentage of young people with health insurance increased by 3.8 points from the first quarter of 2010 to the first quarter of 2011, far outstripping gains in other age groups.6 However, the reliance on expanding dependent coverage to address the high levels of uninsured young adults contains the potential for unintended consequences, because concerns about confidentiality could disrupt access to care.     

Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act

Objectives. We examined preventive care use by nonelderly adults (aged 18–64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.Methods. We used data from the 2005–2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.Results. There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.Conclusions. Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.The benefits of many preventive health care services are well-established.1 In the case of immunization, for instance, those who receive the recommended services are likely to avoid a variety of life-threatening diseases while promoting herd immunity and protecting individuals who are unable to be immunized.2 Those appropriately screened for cancer are likely to receive more timely diagnosis and treatment, which ultimately leads to better outcomes.3 Furthermore, early detection of heart disease, diabetes, and other chronic conditions can lead to the promotion of healthier lifestyles and better management of the diseases.4 Despite this evidence, many studies have shown the use of preventive services, including cholesterol checks, Papanicolaou (Pap) tests, mammograms, colon cancer screenings, and flu vaccines to be below recommended levels.5–9In recent years, the growing prevalence of obesity and chronic conditions and the evidence that modifiable behaviors are among the leading causes of death have led to a renewed emphasis on promoting health and wellness as opposed to treating disease.10,11 This emphasis on prevention was particularly evident in the national conversation leading up to the passage of the Affordable Care Act (ACA) in March 2010. Increasing access to preventive care was one motivation for expanding coverage to the uninsured, and was the explicit goal of an additional provision in the ACA requiring private insurers to cover recommended preventive services without any cost-sharing obligations to consumers. The effects of these ACA policies on preventive service use will depend on the extent to which preventive services are currently underused and whether expanding coverage will increase the receipt of these services.We examined the receipt of 8 preventive services by nonelderly adults in the years before the ACA (2005–2010), thus providing recent evidence on the extent of underuse of a variety of important services. Previous studies have found that lower rates of service use are generally associated with more limited education, low incomes, and a lack of insurance coverage12–14; we concentrated on the disparities in service use between the lower-income adults most likely to benefit from the ACA coverage expansion and their higher-income counterparts. Using a regression-based decomposition analysis, we identified the roles of insurance coverage, education, and other factors in explaining these income-related disparities. The results provide important insights on the potential of ACA efforts to increase the use of preventive care through coverage expansion as well as on the limitations of such efforts.Our conceptual framework relies on human capital models, which suggest that the demand for medical care is derived from the demand for health.15,16 According to such models, critical factors that are expected to affect the demand for health and medical care include age, health status, education, and rate of time preference. In some cases, the effects of these factors on demand for preventive care may be distinct from their effects on demand for treatment. In the case of age, for example, the demand for treatment, or curative care, is expected to increase with age as an individual’s health depreciates, whereas investment in preventive medical care is expected to decrease with age as the payoff period for avoiding future illness shortens.13,17 This reflects a more general distinction between investment and consumption considerations in the demand for preventive care, which is also relevant with respect to the role of health status. From a consumption perspective, those in poor health are more likely to use preventive services, but healthy individuals and those who are future-oriented are also more likely to invest in health and preventive care.18,19 Lastly, although the effect of education on the demand for health and health care is theoretically ambiguous,15 considerable empirical evidence finds a positive relationship between education and prevention activities.13,20–22Another critical consideration is the influence of insurance coverage on the demand for medical care. The direct effect of insurance is to lower the out-of-pocket cost of medical care and thus increase the demand for services. The RAND health insurance experiment provides the most rigorous evidence that this is the case,23 but many other studies provide empirical evidence that having health insurance is associated with increased utilization of medical care.24–27 The possibility exists, however, that because insurance coverage protects against the financial costs of adverse health events, it may reduce the incentive to invest in preventive care.17 Despite this potential for “ex ante moral hazard,” most empirical evidence finds that those with insurance coverage use more preventive care, including blood pressure screenings, mammograms, and other cancer screenings.28–30 Furthermore, those with more generous coverage and lower cost-sharing exhibit higher rates of preventive service use.31–33The ACA includes several components that expand coverage and reduce cost-sharing and thus have the potential to increase the receipt of recommended preventive care. The ACA includes an optional expansion of Medicaid for those with incomes less than 138% of the federal poverty level (FPL) and federal subsidies to purchase coverage in the new health insurance exchanges for those with incomes up to 400% of the FPL. The law also includes penalties for not having health insurance coverage and enhanced enrollment and outreach efforts. When fully implemented, the ACA is expected to significantly expand coverage, particularly among adults with incomes less than 400% of the FPL.34 Many of those becoming newly insured under the ACA are expected to experience improved access to recommended preventive services, given that these services will be included at no or low cost in exchange plans and under most Medicaid plans.In addition to the broader coverage expansions included in the ACA, the law includes new requirements for private health insurance coverage of a set preventive services rated “A” or “B” by the US Preventive Services Task Force.35 After September 2010, many private health plans were required to cover the specified services, and to do so at no cost to members. Although coverage for some of the ACA-mandated services is already relatively common, other services, such as diet and tobacco counseling, are likely to see expanded coverage under the law.36 Furthermore, with the notable exception of mammograms, few of the mandated services are currently required to be covered by private plans under state laws.37     

Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults

Objectives. We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.Methods. We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992–2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.Results. The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.Conclusions. Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.Implemented in 1965, Medicaid was designed as publicly funded health insurance coverage for indigent US citizens and legal permanent residents. The program is jointly funded by the state and federal governments, and states are mandated to provide coverage for children younger than 6 years whose family incomes fall below 133%, children between ages 6 and 17 years whose family incomes fall below 100%, and pregnant women whose incomes fall below 133% of the federal poverty level, as defined by the US Department of Health and Human Services1; individuals who are aged, blind, or disabled and who are eligible for Supplemental Security Income; and low-income Medicare beneficiaries. This program has provided health insurance access to a significant number of previously uninsured low-income Americans and continues to be the only route to health care coverage for many people.Nationwide, Medicaid coverage has been found to be associated with several positive outcomes. Medicaid recipients have greater access to medical treatment than uninsured individuals and, therefore, fewer emergency department visits.2–6 Medicaid enrollees have better overall health and lower mortality rates over time than uninsured persons, likely because they have increased access to treatment.7–10 As a result, their medical care is significantly less costly to society, because health problems are more likely to be addressed before the onset of complications and adverse outcomes.11Although the implementation of the Medicaid program has been a largely successful attempt to provide medical insurance, a significant number of low-income adults remain uninsured, mainly because childless adults without qualifying disabilities are ineligible.12–14 In response to this disparity, some states have developed programs to broaden eligibility criteria through a Section 1115 waiver. Massachusetts was among the first states to implement such an initiative, establishing the MassHealth program in July 1997. Among other provisions, the program extended Medicaid eligibility to families and childless adults whose incomes fell below 200% and 133% of the federal poverty level, respectively. MassHealth was jointly funded by the federal and state governments, with Massachusetts paying for roughly 46% of the program.15,16Outcome evaluations of the MassHealth program demonstrated it to be remarkably successful, with significant declines in uninsured rates, particularly among childless adults who would otherwise be ineligible for Medicaid coverage.17,18 Research by Long et al. found that the MassHealth program resulted in a 33% decrease in the rate of uninsured Massachusetts residents.19 Furthermore, Quigley et al. reported that the MassHealth program covers nearly 1 in 6 Massachusetts residents.15 Consequently, it is estimated that only 6% of adults and 3% of children in Massachusetts remained uninsured after implementation of the program.Although evaluations of MassHealth have provided strong support for the program, some evidence suggests that certain marginalized populations are less affected by Medicaid expansion policies than others.16,20 Despite meeting the income eligibility criteria, many people living in poverty remain uninsured because they don''t know they are eligible, they don''t know how to obtain coverage, or they lack any form of identification.21,22 Homeless adults are disproportionately affected by lack of insurance and are reportedly difficult to enroll in public insurance programs.23,24 Although Massachusetts developed several approaches for targeting this hard-to-reach population, evidence suggests that the effort to enroll homeless adults and keep them enrolled faces many logistical barriers.16These challenges are even greater among homeless individuals with substance use disorders. These disorders are common among homeless persons, with prevalence estimates of 40% to 60%.25,26 These individuals generally have significantly greater health care needs, for treatment of, for example, psychiatric disorders, HIV and other sexually transmitted infections, hepatitis, liver disease, lung disease, and wound and skin infections.27–30 The premature mortality rate is significantly higher for homeless individuals than for the general population,27,31 and homeless people with substance use disorders are even more disproportionately affected.31,32 Finally, substance abuse is among the strongest predictors of returning to homelessness among formerly homeless individuals.33–36 Therefore, homeless adults'' lack of the Medicaid coverage necessary to obtain treatment is a significant public health concern.Assessing the impact of MassHealth is especially important in the context of national policy initiatives. Currently, many low-income childless adults qualify for Medicaid benefits because of a physical or mental health disability, but substance abuse is not among the conditions that confer eligibility, so many substance-abusing homeless adults who do not have children are ineligible for Medicaid coverage. However, a major provision of the Affordable Care Act is that all individuals with incomes that fall at or below 133% of the federal poverty level will be eligible for Medicaid effective January 2014, irrespective of parental or disability status. Although a Supreme Court ruling in June 2012 rejected a mandate for states to expand coverage,37 it is still expected that a significant portion of individuals with substance use disorders will benefit tremendously from the law''s expanded eligibility.To date, no large-scale quantitative evaluation has attempted to determine whether marginalized population groups, such as homeless substance-abusing adults, still have difficulty obtaining coverage under the Medicaid expansion.16,20–24 Data from state programs such as MassHealth are useful in assessing whether these groups will benefit from Medicaid expansion to the same extent as other population groups or may be in need of targeted interventions to improve their access. We examined administrative data on admissions to substance abuse treatment programs from 1992 to 2009 to assess the uptake of Medicaid coverage by substance-abusing homeless adults after the implementation of MassHealth in 1997. We assessed whether homeless adults entering substance use disorder treatment programs were less likely than housed adults to be covered by Medicaid. To rule out the potential impact of secular trends in national Medicaid coverage, we compared uptake of Medicaid coverage in adults entering substance abuse programs after 1997 in Massachusetts with rates in other states.     

The Affordable Care Act: The Value of Systemic Disruption

It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA), anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve.Passage of the ACA broke the political logjam that long stymied national progress toward equitable, quality, universal, affordable health care. It extends coverage for the uninsured who are disproportionately low income and people of color, curbs health insurance abuses, and initiates improvements in the quality of care. However, challenges to affordability and cost control persist.Public health advocates should mobilize for coverage for abortion care and for immigrants, encourage public-sector involvement in negotiating health care prices, and counter disinformation by opponents on the right.It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA),1 anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve. Passage of the ACA was a historic political achievement, breaking the logjam that long stymied national progress toward equitable, quality, universal, affordable health care in the United States. It has survived considerable challenges: a fractious legislative road to adoption in 2009 and 2010, more than 30 votes for repeal in Congress in 2011 and 2012, a Supreme Court case, and the national election of 2012. However, the benefits as well as the limits of this complicated law are poorly understood by the public,2 and opposition will likely persist. In part, this is because major provisions of the law have not yet been fully implemented, in particular the expansions of coverage through health insurance exchanges and Medicaid, although implementation will create other problems. In addition, the ideological and structural barriers to a more functional health care system have been weakened but not eliminated.     

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485).Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.Lack of health insurance is associated with lower rates of preventive care, delays in necessary care, forgone care, medical bankruptcy, and increased mortality.1–5 The Affordable Care Act (ACA; Pub L No. 111–148) expanded Medicaid insurance for people with low incomes (< 138% of the federal poverty level [FPL]) in 31 states. However, whether Medicaid coverage improves health outcomes remains controversial. Several studies described differences in chronic disease prevalence and control between uninsured persons and those with Medicaid, but have not been designed or powered to explore whether Medicaid coverage might cause these differences.6–8Some have suggested that Medicaid’s low reimbursement rates discourage physician acceptance of Medicaid patients, limiting access to care and resulting in poor health outcomes.9,10 Recently, the Oregon Health Insurance Experiment (OHIE), a randomized, controlled trial, found that Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.11–13 However, the OHIE did not find improvements in other important health outcomes such as control of other chronic diseases, fueling Medicaid’s critics.14,15The rigorous design of the OHIE provides strong evidence on the impact of Medicaid in the Portland, Oregon, metropolitan area where it was conducted. However, Portland’s relatively robust medical safety net for the uninsured16,17 may have attenuated the potential for health improvements from Medicaid expansion compared with other locales, or the United States as a whole.We used the nationally representative National Health and Nutrition Examination Survey (NHANES) to compare outpatient physician visit frequency among the uninsured and comparable persons with Medicaid coverage. We also assessed whether individuals with major chronic conditions had been previously diagnosed with the condition, and whether it was under control.     

Children’s Insurance Coverage and Crowd-Out Through the Recession: Lessons From Ohio

Objectives. We estimated changes in children’s insurance status (publicly insured, privately insured, or uninsured) and crowd-out rates during the 2007 to 2009 US recession in Ohio.Methods. We conducted an estimate of insurance coverage from statewide, randomized telephone surveys in 2004, 2008, 2010, and 2012. We estimated crowd-out by using regression discontinuity.Results. From 2004 to 2012, private insurance rates dropped from 67% to 55% and public rates grew from 28% to 40%, with no change in the uninsured rate for children. Despite a 12.0% decline in private coverage and a corresponding 12.6% increase in public coverage, we found no evidence that crowd-out increased during this period.Conclusions. Children, particularly those with household incomes lower than 400% of the federal poverty level, were enrolled increasingly in public insurance rather than private coverage. Near the Medicaid eligibility threshold, this is not from an increase in crowd-out. An alternative explanation for the increase in public coverage would be the decline in incomes for households with children.During the economic recession of 2007 to 2009, 8 million Americans lost employer-sponsored health insurance.1 During this same period, the national rate of uninsurance among adults increased by 15% while the rate for children decreased by 7%, as children increasingly moved from private insurance to public programs including Medicaid and the Children’s Health Insurance Program (CHIP).1 With spending for Medicaid accounting for almost 20% of state budgets,2 increases in Medicaid enrollment raise concerns for many state governments. A key debate among state legislators is whether these changes represent Medicaid fulfilling its planned role as a safety net or whether these increases represent Medicaid replacing or crowding-out private insurance coverage.Crowd-out refers to individuals who are insured by a public program but who otherwise would have private insurance if the public program did not exist. The archetype of crowd-out is when privately insured individuals gain eligibility for Medicaid and drop their private coverage to enroll in the public plan. This scenario is often referred to as public–private “substitution” in the literature.3 It should be noted that individuals who can no longer afford private individual insurance or who lose access to, or cannot afford their employer-sponsored plan, are excluded from crowd-out estimates. For example, a child whose parent has private insurance but cannot afford to include the child on the plan4 would not be considered to be crowded out. The second type of crowd-out, which we refer to as continuation crowd-out, occurs when an individual on a public program becomes eligible to enroll in an employer-sponsored private plan, but chooses to remain on public coverage. This scenario could occur when an unemployed parent begins a new job that offers an affordable, employer-sponsored plan, but the parent decides to keep their child enrolled in Medicaid instead of the newly available private option.The published literature primarily focuses on estimates of crowd-out based on increased enrollment following the expansion of eligibility, such as a state increasing Medicaid income eligibility limits. These estimates vary widely, ranging from high estimates of 50% (i.e., half of individuals gaining Medicaid coverage through an expansion would otherwise have private insurance) to other authors finding near zero crowd-out.5–7 Some of this variability is driven by the sensitivity of the econometric models used8 and some may be attributable to the actual crowd-out that occurred with different expansions of eligibility in different states.5 A smaller literature directly measures substitution from survey data, finding low levels of this type of crowd-out.9,10 From a legislative perspective, these crowd-out estimates reveal the budgetary cost of Medicaid expansions. For the average state in 2012, insuring a child through Medicaid cost $2700 per year.11 At a 50% crowd-out rate, a state would need to budget $5400 to reduce the number of uninsured by 1 child. The $5400 would include coverage for the previously uninsured child and for a second child who previously had private insurance (1 uninsured child and 1 case of crowd-out).The existing crowd-out literature implicitly assumes that crowd-out estimates are stable over time. The econometric approaches used in most studies require a change in Medicaid eligibility to estimate crowd-out, producing a single, national estimate for the policy change.5,12 Absent a more recent change, policymakers assume that crowd-out rates do not change with time because those estimates are not time dependent. This implicit assumption, though, is likely invalid. Crowd-out indicates the use of public insurance while private coverage is still available; the reasons for that are likely dependent on the current cost and expected future cost of insurance, the suitability of access provided by the types of coverage, and noneconomic factors such as the stigma associated with public coverage.13Each of these factors can change over time. Concern about the future cost of insurance during the recession may have been particularly important, as parents may have had strong concerns about retaining their employment or concerns that their employer would stop offering employer-sponsored health insurance. Between January 2007 and January 2010, Ohio’s unemployment rate almost doubled from 5.4% to 10.6%.14 This increase in the unemployment rate may have raised parents’ concerns about future access to health care for their children. If these concerns led to increased enrollment in public insurance, then crowd-out would increase. Previous work has not estimated state-level crowd-out levels over time. We evaluated how many children in Ohio moved from private health insurance to public health insurance and the degree to which those children were crowded out between 2004 and 2012. We estimated total crowd-out (substitution plus continuation) over time to see whether crowd-out levels changed during the recession in Ohio.     

Welfare reform and older immigrants' health insurance coverage

Objectives. I examined changes in older immigrants'' health insurance coverage after welfare reform in the United States to determine whether the reform measures achieved their goal of saving money by reducing Medicaid participation without increasing the number of uninsured people.Methods. Data were obtained from older adults who participated in the Current Population Survey''s Annual Social and Economic Supplement from 1994 to 1996 and 2001 to 2005. I used logistic regression to estimate changes in the sample''s Medicaid and health insurance coverage after welfare reform, paying special attention to noncitizens and recent immigrants.Results. Older immigrants'' health insurance status was associated with their citizenship status and length of stay in the United States. Medicaid participation significantly decreased among noncitizens and recent immigrants but increased among naturalized citizens. Private health insurance and employer-sponsored insurance coverage significantly increased among recent immigrants but decreased among established immigrants and naturalized citizens. The probability of being uninsured did not significantly change among any group of immigrants.Conclusions. Given increases in postreform Medicaid participation among some immigrant groups, my findings suggest that the long-term cost-saving effectiveness of the current restrictive Medicaid eligibility policy is doubtful.The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 dramatically limited immigrants'' access to Medicaid by imposing restrictive eligibility rules. The Personal Responsibility Act was intended to reduce the costs of public-assistance programs by shifting the responsibility for supporting poor immigrants away from the federal government and onto individual immigrant households.¹ This legislation prohibited states from providing federally funded Medicaid to postenactment immigrants (those who immigrated to the United States after the law was enacted) during their first 5 years in the country, and it granted states the right to determine the Medicaid eligibility of preenactment immigrants (those who entered the United States before the law was enacted) and of postenactment immigrants after their first 5 years in the country. During the study periods, most states provided Medicaid to noncitizens eligible for federally funded Medicaid, and several states (e.g., California) provided state-funded Medicaid to postenactment immigrants subject to the 5-year ban. The Personal Responsibility Act also imposed the “deeming” process, which requires benefit-granting agencies to include the income of immigration sponsors (those who invited immigrant applicants to the United States) when determining noncitizens'' financial Medicaid eligibility. As a result, noncitizens—especially recent immigrants—have had very limited access to Medicaid since the law was enacted.^2,3There has been little research on whether or how these policy changes have affected older immigrants'' health insurance coverage. Existing studies focus on younger immigrants, such as children or working-age adults. These studies show that after welfare reform, Medicaid participation rates declined more rapidly among immigrants than among natives.^4–6 A few studies have investigated welfare reform''s effects on immigrants'' health insurance coverage and Medicaid participation. Based on findings from a nonelderly sample, Borjas⁴ argued that Medicaid eligibility restrictions did not affect health insurance coverage among noncitizens. Although strict eligibility rules discouraged noncitizens'' Medicaid participation, the new rules also encouraged noncitizens'' participation in employer-sponsored health insurance. As a result, the percentage of immigrants with health insurance coverage remained stable (at approximately 61%) after welfare reform.However, another study, which focuses on a more vulnerable population, told a different story: among the children of foreign-born single mothers, the percentage uninsured increased by 9% after welfare reform, whereas the percentage uninsured among the children of native single mothers increased by only 2%.⁷ Carrasquillo et al.⁸ estimated that 100 000 to 140 000 uninsured immigrant children and 250 000 uninsured immigrant parents would become eligible for Medicaid if noncitizen restrictions were repealed.Although these studies are valuable, they are limited by their focus on younger populations. Older immigrants warrant study as a separate group because they often face challenges that younger immigrants do not. For example, older immigrants are less able to learn English and memorize new information, which may make it harder for them to pass the US citizenship test.⁹ In addition, their labor market participation rate is generally low,¹⁰ which may make it harder for them to counter eligibility restrictions by working. Furthermore, older adults tend to have poorer health^11–13 and to need health insurance more urgently than do their younger counterparts do. Finally, the proportion of immigrants among older adults increased from 8.6% in 1990 to 10.8% in 2003.¹⁴ These facts indicate that health care policymakers should study the needs of this vulnerable but growing population.To the best of my knowledge, only 1 study has conducted separate analyses of older immigrants'' Medicaid participation. Fix and Passel⁵ showed that older noncitizens'' Medicaid participation remained the same (28.2%) between 1994 and 1997, whereas older naturalized citizens'' Medicaid participation increased from 11.1% to 14.9% during the same period. However, Fix and Passel''s study was limited because it examined neither private insurance coverage nor the uninsurance rate, its study period ended just after welfare reform (1997), and it did not provide information on recent immigrants who were ineligible for federally funded Medicaid. To fill the gaps in existing research, I examined the way Medicaid participation and health insurance coverage changed among older immigrants after welfare reform, to determine whether the reform measures achieved their goal of saving money by reducing Medicaid participation without increasing the number of uninsured people.     

The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.The Affordable Care Act (ACA) focuses on improving access and quality by expanding insurance coverage, using payment reform strategies, and increasing quality reporting.1 In the ACA, hospital-based emergency departments (EDs) are referenced as places to be avoided and reduced; no new payment models focus on ED care, and there are no plans to broadly address ED-specific quality through new measurement programs.Promoting value in ED care needs to be a greater focus for policymakers as the ACA is implemented. Emergency departments play a central role in health care delivery as the staging area for the ill and injured, and as an always-available resource for unscheduled care. Emergency department physicians constitute less than 5% of the US physician workforce, yet manage 28% of acute care encounters.2 Historically, the need for EDs arose from increases in vehicular trauma that accompanied the expansion of the Interstate Highway System in the 1960s.3 However, EDs also quickly became providers of low acuity unscheduled care as well.4 The Emergency Medical Treatment and Active Labor Act legislation passed in 1986 institutionalized EDs as provider of last resort for all, regardless of their ability to pay. Emergency departments have replaced the community physician’s office as the primary source for hospital admissions and provide a safety net for the uninsured, underinsured, and medically disenfranchised.5,6Several elements of the ACA—the insurance expansion, patient-centered medical homes, accountable care organizations, and bundled payments—will directly affect both demand for ED care and expectations for its role in providing coordinated care. We explore these effects and suggest some practical ways that EDs can be better integrated into these efforts.     

Latino Population Growth and Hospital Uncompensated Care in California

Objectives. We examined the association between the size and growth of Latino populations and hospitals’ uncompensated care in California.Methods. Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models.Results. We found a significant association between the growth of California’s Latino population and hospitals’ uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant.Conclusions. Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals’ uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.Uncompensated hospital care for the uninsured and underinsured imposes a significant financial burden on the US health care system. The American Hospital Association reported that uncompensated care rose to $45.9 billion in 2012, which accounted for 6.1% of total hospital expenses that year.1 This problem affects hospitals’ financial stability and ability to recoup losses from reduced payments, which in turn can hurt their ability to care for the local population, operate emergency department and specialty services to meet patient needs, and maintain optimal nurse staffing ratios.2–4Hospitals have typically responded to increased uncompensated care by increasing prices for paying patients5; however, Medicaid and Medicare payments have been reduced, and it has become more difficult to shift costs to private payers. Uncompensated care also affects all levels of government, which provide subsidies to offset these losses through other programs.6 The largest source of federal funding for uncompensated care—Medicaid Disproportionate Share Hospital (DSH) payments—totaled $11.4 billion in 2012.7 Despite these mechanisms that indirectly subsidize hospitals’ provision of uncompensated care, hospital closures have been linked to uncompensated care.8Hospital administrators, policymakers, and advocates for the uninsured hoped that the Patient Protection and Affordable Care Act (ACA) would provide health insurance to many of the almost 50 million previously uninsured Americans and thereby significantly reduce uncompensated care. The Supreme Court’s decision on the ACA allows states to opt out of the mostly federally funded Medicaid expansion, which will likely lower the projected numbers of Americans who obtain coverage and potentially undermine the predicted decreases in future uncompensated care by hospitals.9 Existing policy efforts focus on decreasing hospital payments to reduce health care spending,10 and DSH payments are being reduced in anticipation of increases in insurance coverage in all states.11 These recent health policy developments have brought the problem of uncompensated hospital care into a new focus, generating increasing interest in understanding what factors affect hospitals’ financial stress.Some have suggested that immigrants use large amounts of uncompensated care,12 potentially implicating the Latino population—the nation’s largest immigrant group13—in rising uncompensated care. However, hospital uncompensated care may also decrease because of Latinos’ low health care utilization14–21 and expenditures,22–25 which have been described in the context of the healthy immigrant effect (i.e., Latino immigrants are usually younger and healthier than Latinos born in the United States)26 and other factors (e.g., fewer available health care resources, lack of linguistically appropriate care, discrimination in health care settings, and fear of deportation among undocumented Latinos).27,28 Empirical evidence for the potential impact of changing Latino demographics on hospitals’ uncompensated care is limited at best. A study of Oregon state data found weak evidence of an association between the size of the Latino population and hospital uncompensated care.27 A nonsignificant relationship might have reflected Latinos’ immigrant status, limited health care access, and unwillingness or inability to seek health care.California’s hospitals account for more than 10% of uncompensated care nationally.29 California has the largest Latino population of any state, as well as the largest growth rate in its Latino population.29 In 2012, 44.5% of California''s uninsured population was Latino.30 Among the uninsured Latino population in the state, more than 1 million will remain uninsured, even after the ACA’s coverage expansions.31,32 Although some are able to temporarily access emergency Medicaid services for significant, emergent health issues, the majority are uninsured and require help from local indigent care programs, hospital charity care, federally qualified health centers, or other safety net providers. Hence, California, because of its high number (7 million) and percentage (20%) of uninsured residents prior to the ACA,33 offers an excellent setting to study the impact of the Latino population on the uninsured rate, uncompensated care need, and local safety net providers.We examined the association between Latino population growth rates and hospitals’ uncompensated care in California between 2000 and 2010. These growth rates not only reflected the marginal increases in uncompensated care and Latino population estimates, but also took into account baseline levels of these variables. Because growth rates are considered to be better than the level measures for predicting future population growth trends,34 our findings could have important policy implications regarding the allocation of health care resources.     

Health Care Coverage and the Health Care Industry

Objectives. We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category.Methods. We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype.Results. Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI] = 2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI = 3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR] = 1.5; 95% CI = 1.0, 2.4).Conclusions. Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern.For complex socioeconomic reasons, private health insurance, typically provided by an employer, is “the dominant mechanism for paying for health services” in the United States.^1(p79) According to the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, analyses of data from the Current Population Survey (CPS) show that, in 2006, 54% of the US civilian, noninstitutionalized population had employer-sponsored health insurance; 5% had private, nongroup health insurance; and 26% had public health insurance coverage. Approximately 46 million US residents (16% of the population) are currently uninsured.² Numerous studies have shown that, relative to people with health insurance, uninsured people receive less preventive care, are diagnosed at more advanced disease stages, and, once diagnosed, tend to receive less therapeutic care and have higher mortality rates.^3–8Although national uninsurance trends are well-documented, the rate of uninsurance within the health care workforce has received scant attention. Given that health care employment rates are increasing at a more rapid pace than overall employment rates, this lack of attention is especially worrisome. According to the Bureau of Labor Statistics, nearly half of the 30 occupations in which employment opportunities are growing fastest are health care occupations. For example, whereas the Bureau of Labor Statistics projects that overall employment will increase about 10% from 2006 to 2016, employment opportunities for personal and home care aides are projected to increase nearly 51%, and opportunities for physical therapist assistants are expected to increase by a third. The Bureau of Labor Statistics also projects that, by 2016, new job opportunities for registered nurses will increase by approximately 24% (approximately 587 000 new jobs).⁹Although the overall employment outlook for health care workers is promising, what is less clear is to what degree employment in health care is associated with health insurance coverage. A 2001 General Accounting Office report suggested that one fourth of nursing home aides and one third of home health care aides were uninsured.¹⁰ The Kaiser Family Foundation reported that the uninsured rate among workers in the health and social services industry was 23% in 2007.¹¹ On the basis of a review of the literature in the health and human services occupations, Ebenstein concluded that the health insurance plans offered to direct care workers in the developmental disabilities field are “inferior … with less coverage and more out-of-pocket expenses” and that fewer direct care workers “are able to afford health coverage even if they are eligible.”^12(p132)Taking a more comprehensive look at the US health care workforce, Himmelstein and Woolhandler¹³ used 1991 CPS data to estimate uninsurance rates among physicians and other health care personnel. They reported that, overall, 9% of health care workers were uninsured, along with more than 20% of nursing home workers. Examining CPS data from 1988 to 1998, Case et al. found that uninsurance rates among all health care workers rose from 8% to 12%, that rates increased more for health care workers than for workers in other industries, and that rates differed according to occupation and place of employment.¹⁴ For example, occupation-specific uninsurance rates were 23.8% among health aides, 14.5% among licensed practical nurses, and 5% among registered nurses, whereas place-specific rates were 20% among nursing home workers, 8.7% among medical office workers, and 8.2% among hospital workers.¹⁵In their studies, Himmelstein and Woolhandler¹³ and Case et al.¹⁴ used national-level data to estimate uninsurance trends among health care workers. However, these trends were not adjusted for health care workers'' social, demographic, or economic characteristics, which would have helped explain variation across categories or over time. Moreover, with the growth of the health care workforce, estimates from these older studies probably do not reflect the current situation. As a result, the picture of uninsurance as it pertains to the health care workforce lacks the precision and currentness necessary for sound policy decisions. In an effort to expand knowledge in this area, produce more up-to-date estimates, and provide support for possible policy decisions, we used data from the National Health Interview Survey (NHIS) to examine uninsurance among workers in the health care industry.     

Persistent disparities in the use of health care along the US-Mexico border: an ecological perspective

Objectives. We examined disparities in health care use among US–Mexico border residents, with a focus on the unique binational environment of the region, to determine factors that may influence health care use in Mexico.Methods. Data were from 2 waves of a population-based study of 1048 Latino residents of selected Texas border counties. Logistic regression models examined predictors of health insurance coverage. Results from these models were used to examine regional patterns of health care use.Results. Of the respondents younger than 65 years, 60% reported no health insurance coverage. The uninsured were 7 and 3 times more likely in waves 3 and 4, respectively, to use medical care in Mexico than were the insured. Preference for medical care in Mexico was an important predictor.Conclusions. For those who were chronically ill, old, poor, or burdened by the lengthy processing of their documents by immigration authorities, the United States provided the only source of health care. For some, Mexico may lessen the burden at the individual level, but it does not lessen the aggregate burden of providing highly priced care to the region''s neediest. Health disparities will continue unless policies are enacted to expand health care accessibility in the region.Current political discourse on undocumented immigration and national security has heightened public awareness of the US–Mexico border. Arguments for tightening access to this border are proliferating in politics, the media, and the public at large. National debates highlight crossings from Mexico to the United States but largely ignore significant border crossings in the other direction. Because they are less controversial, crossings to the south are not publicized by the media; yet thousands throughout the southwestern United States cross monthly to obtain health care services in Mexico.Use of health care services in Mexico by border residents is a well-documented, decades-old practice.^1–5 Much of what is known about it is based on limited samples,^6–8 the targeting of specific health care needs or products,⁹ customs declarations,¹⁰ or participant observation.¹¹ In recent years, this literature has grown to include options for extending US health care coverage across the border in the form of the expansion of Medicare and the availability of cross-border private health insurance coverage.^12–14Accounts of these crossings have become embedded in Southwestern folklore and common knowledge. Some stories exalt the outright benefits of the personalized attention and time provided by health care professionals in Mexico, whereas others tell of wrongful deaths and incapacitations resulting from poor diagnosis and incorrect treatment.^15–18 Characterizations of these practices vary widely from beneficial and worthwhile to an instrument of last resort primarily because of the lack of affordability of the US health care system.^19,20 Still, substantial knowledge gaps remain because much of what is known is based on anecdotal stories and nonprobability samples of border residents.In this study, which had an ecological perspective,^21,22 we considered regional health insurance coverage, the border economy, and the confluence of 2 health care systems as 3 contextual factors that may significantly influence, beyond cultural preferences, the use of health care in Mexico. In particular, the South Texas region''s high level of uninsurance is considered as a pivotal influence on health care use in Mexico. Existing explanations for uninsurance in the United States, which acknowledge area and regional variations to some extent, nonetheless typically emphasize individual characteristics, resulting in a national profile of the uninsured as poor, at a certain age, a minority, or an immigrant and unskilled worker.^23–27 This national profile of the uninsured describes important individual traits but diminishes the influence of ecological factors in accounting for significant regional variations in uninsurance rates. Although in the larger national context these individual attributes are major determinants of uninsurance, in the context of the US–Mexico border, these conditions are intensified by a binational economy and the unique characteristics of the health care systems in the United States and Mexico.Data for this study came from the Border Epidemiological Study of Aging (BESA), an ongoing population-based study of Texas residents in selective border counties. Although only Texas border counties were included in this research, socioeconomic and demographic structures along the border are sufficiently similar to warrant the broader consideration of these findings in the region, with the exception of San Diego County, California.²⁸The proportion of the population without health insurance coverage—like many other aspects of health care and health—varies substantially by region. The 4 southwestern border states have uninsurance rates exceeding 18% and account for 30% of the total uninsured US population, with approximately 12 million uninsured residents.²⁹ About 26% of the children and adults in Texas are uninsured, with uninsurance rates particularly high in border communities (38%).²⁹The border economy is anchored on the Mexican labor market. It is characterized by low wages and composed of mostly services, manufacturing, and agribusiness industries²⁸ that typically pass on the high cost of health insurance premiums to their employees. The region''s low wage structure resulted in a median annual household income of $25 433 in 2004 dollars before taxes for the counties studied, compared with $47 453 nationally.³⁰ We estimated that at least 43% ($10 880 ÷ $25 433) of the household income in these counties, on average, would have to be spent on family health insurance premiums to cover all family members, almost twice the percentage of the rest of the United States.³¹ The US health care system is therefore rendered unaffordable for most border residents, even when employers may offer health insurance coverage.The private sector of the health care system in Mexico maintains a competitive cost advantage over the US system and provides an alternative for US border residents who cannot afford US health care. This private sector in Mexico is literally well positioned near the border to ease access for patients from the United States. Medical doctors, pharmacies, and private clinics aggressively market their services in the US local media.The price of health care north of the border is anchored within the larger systemic characteristics of the US health care system. Health insurance coverage premiums and health costs in US counties along the US–Mexico border are determined by national and statewide price structures. Instead of being discounted to take the border resident''s low income into account, costs are higher than in the rest of the United States. For example, Dartmouth Atlas of Health Care estimates of total Medicare expenditures per enrollee were at the 95th percentile for the South Texas border region in 2003.³² Moreover, Medicare, Medicaid, and most US private health insurance companies do not provide coverage in Mexico.³³We hypothesized that as the health care system in the United States becomes increasingly expensive relative to the alternative in Mexico, the incentive to cross the border for health care will remain an important option for border residents and an important dimension of the border''s social context. Between 2001 and 2005, the period of this analysis, health care inflation in the United States was as high as 60%.³⁴ Therefore, our data allowed unique insights into how the high health care inflation in the United States affected health insurance coverage rates and health care use in Mexico by US border residents.We drew on the previous considerations to investigate the use of health care services in Mexico by border residents. First, we identified significant predictors of health insurance coverage for US border residents. Second, we used these predictors to analyze how factors related to US-based health insurance coverage and the preference for Mexican medical care were associated with the use of medical care south of the border. Third, we explored the association between individual socioeconomic status, health and functional status, years of residence in the United States (for the Mexican-born group), and preference for Mexican medical care in predicting health insurance coverage and use of Mexican medical care.     

Medicaid Enrollment Gap Length and Number of Medicaid Enrollment Periods Among US Children

Objectives. We examined gap length, characteristics associated with gap length, and number of enrollment periods among Medicaid-enrolled children in the United States.Methods. We linked the 2004 National Health Interview Survey to Medicaid Analytic eXtract files for 1999 through 2008. We examined linkage-eligible children aged 5 to 13 years in the 2004 National Health Interview Survey who disenrolled from Medicaid. We generated Kaplan-Meier curves of time to reenrollment. We used Cox proportional hazards models to assess the effect of sociodemographic variables on time to reenrollment. We compared the percentage of children enrolled 4 or more times across sociodemographic groups.Results. Of children who disenrolled from Medicaid, 35.8%, 47.1%, 63.5%, 70.8%, and 79.1% of children had reenrolled in Medicaid by 6 months, 1, 3, 5, and 10 years, respectively. Children who were younger, poorer, or of minority race/ethnicity or had lower educated parents had shorter gaps in Medicaid and were more likely to have had 4 or more Medicaid enrollment periods.Conclusions. Nearly half of US children who disenrolled from Medicaid reenrolled within 1 year. Children with traditionally high-risk demographic characteristics had shorter gaps in Medicaid enrollment and were more likely to have more periods of Medicaid enrollment.Medicaid provided health insurance for approximately one third of children younger than 18 years in 2010.1 However, many children experience gaps in Medicaid enrollment. Some children have gaps in Medicaid enrollment because they gain health insurance coverage from another source, but more than half of children become uninsured during these gaps, despite half of those remaining eligible for Medicaid.2 Gaps in health insurance and in Medicaid coverage specifically have been shown to negatively affect child health3,4 as well as shift care from ambulatory settings to more costly emergency departments and inpatient days.5Gaps in Medicaid enrollment among children have been previously described, although rarely using nationally representative data or even data from multiple states.6,7 Research using Medicaid data from 2005 to 2007 suggests that, among children enrolled in Medicaid at the beginning of 2005, 41.1% were continuously enrolled through 2007, 27.1% disenrolled and reenrolled, and 31.8% disenrolled and did not return to Medicaid by the end of 2007.7 Another recent study showed that, between 2000 and 2004, among children who disenrolled from Medicaid 6 months before, 28.1% had reenrolled in Medicaid and 28.9% had acquired other health insurance.8 However, although some studies have reported on gaps in Medicaid enrollment among children, the characteristics of children who have gaps and the characteristics of those with shorter as compared with longer gaps in Medicaid coverage have not been described. Similarly, other studies have examined the enrollment and disenrollment patterns of children for insurance in general2,9–12 and for Medicaid specifically.7 However, previous studies have not identified the characteristics of children with multiple entrances to and exits from Medicaid over a prolonged period.There has been great interest in trying to develop policies to enroll and retain Medicaid-eligible children in the Medicaid programs.13 Understanding the lengths of Medicaid gaps—as well as the sociodemographic and health characteristics of children with continuous enrollment, shorter gaps, longer gaps, and frequent enrollments and disenrollments—could provide valuable information for states intending to design programs to retain Medicaid-eligible children in Medicaid programs and to reenroll Medicaid-eligible children who have become uninsured.We used a nationally representative sample of children and tracked Medicaid enrollment patterns among children across 10 years to examine 2 specific issues. First, we examined sociodemographic and health characteristics for children with longer versus shorter gaps in Medicaid enrollment. Second, to identify children at greater risk for multiple enrollment periods, we examined the percentage of children with 4 or more enrollment periods in Medicaid within selected sociodemographic and health characteristic groups.     

Change in Health Insurance Coverage in Massachusetts and Other New England States by Perceived Health Status: Potential Impact of Health Reform

Objectives. 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.Methods. 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.Results. 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.Conclusions. 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.The sweeping health reform initiative in Massachusetts, An Act Providing Access to Affordable, Quality, Accountable Health Care (enacted April 12, 2006),1 provides a natural experiment with outcomes that may foreshadow those of the comprehensive national health reform President Obama signed into law 4 years later. The Patient Protection and Affordable Care Act (enacted March 23, 2010)2 and amendments in the Health Care and Education Reconciliation Act (enacted March 30, 2010),3 are collectively referred to as the Affordable Care Act (ACA).This landmark federal law includes provisions to strengthen the public health system, provide mandatory funding for prevention and wellness programs and activities, strengthen the Medicare program, implement insurance market reforms, bolster public health and primary care workforce, and improve the overall quality of the nation’s health system. The act focuses on expanding health insurance coverage and improving the health care delivery system beginning with incremental reforms in 2010 and following up with more substantial changes such as individual mandates, employer requirements, expansion of public programs, premium and cost-sharing subsidies to individuals, premium subsidies to employers, tax changes, and health insurance exchanges in 2014. Importantly, the law also prevents insurers from denying health insurance coverage or charging higher premiums on the basis of health status.4,5 The Congressional Budget Office estimates that, when fully implemented in 2019, ACA will provide coverage to an additional 32 million Americans leaving about 23 million nonelderly people uninsured.6Systematic reviews of the literature on the impact of health insurance on health care utilization and health outcomes provide some convincing and some nuanced conclusions. These reviews consistently report evidence of increased utilization of physician and preventive services, improvements in the health of vulnerable populations, and lower mortality, conditional on injury and disease; however, how health insurance affects health outcomes for nonelderly adults remains unclear.7,8From a public health perspective, monitoring implementation of ACA at federal, state, and local levels will be important because this act will change health insurance coverage and access to care, and uptake of care, including preventive services and needed treatment; may alter health care finance and payment structures and care delivery systems as well as health expenditures; and may modify individual and population outcomes of care and health status. Studying the effects of health insurance would ideally rely on experimental evidence7 where health insurance was randomly assigned like the RAND Health Insurance Experiment and the Oregon Medicaid Lottery.9,10 In the absence of randomized experiments, owing to ethical and practical considerations, the need for conducting some social experiments or other approaches to infer causal conclusions from observational data are essential.7,11Fortunately, a natural experiment of near universal health insurance coverage combined with a targeted public health intervention has been unfolding in Massachusetts for more than 3 years and has been the subject of many studies. Researchers have studied various aspects of the impact of Massachusetts health reform, after 1 year,12 over the short term, comparing 18 months before and 18 months after the reform,13 on young adults and children,14,15 and even the effects of the recession.16 This evolving new body of research leaves a gap in our understanding of the impact of health reform by perceived health care need. We examined the impact of the Massachusetts health reform and its public health component on change in health insurance coverage by perceived health. We examined the impact of the natural experiment in Massachusetts as a model to predict likely outcomes of implementing ACA. Because Medicare already covers most of those aged 65 years and older we compared the effectiveness of mandatory versus optional health insurance among only the nonelderly adult population (aged 18–64 years) residing in Massachusetts and other New England states (Connecticut, Maine, New Hampshire, Rhode Island, and Vermont).To do this, we compared data between the 3 years (2003–2005) before and the 3 years (2007–2009) after Massachusetts enacted the health reform law and between Massachusetts and other New England states that had no similar health reform laws. Massachusetts and other New England states had similar sociodemographic population characteristics and macroeconomic profiles (e.g., gross domestic product, unemployment rates) over this time period, including a similar impact of 2 years of recession (2007–2009).17,18 This allows not only “before-versus-after” but also “with-versus-without” analyses, a strategy employed by other researchers to explicate the impact of health reform laws and policy as a control for other elements.16,19We used the Behavioral Risk Factor Surveillance System (BRFSS), the largest and longest-running state-representative, population-based telephone survey that has asked questions about health insurance coverage, health-promoting and health-compromising behaviors, and doctor-diagnosed chronic conditions. Existing federal government and state-sponsored surveys generate different estimates of uninsurance possibly explained by differences in survey design including coverage, reference period, mode, and questionnaire design (wording and placement of questions).20–22 First, we established the quality and the consistency of BRFSS health insurance coverage estimates by comparing these estimates for selected demographic and socioeconomic characteristics with other federal surveys that gather data on health insurance—the American Community Survey (ACS), the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC), and the National Health Interview Survey (NHIS). The US Census Bureau added a question about health insurance to the 2008 ACS leading to the release of the first set of estimates in September 2009.23 The CPS ASEC is the most widely cited source for health insurance statistics. It is annual, timely, relatively large, and has a state-based design. The NHIS is a continuing nationwide survey conducted by the National Center for Health Statistics.23We hypothesized a greater increase in the proportion of nonelderly adults with health insurance coverage in Massachusetts than in other New England states. We further hypothesized that nonelderly adults with greater perceived health care needs would be more likely to obtain health insurance coverage. Groups with greater perceived health care need would show a larger increase in health insurance coverage from prereform to postreform and in Massachusetts compared with other New England states.     

Dental Care Coverage and Use: Modeling Limitations and Opportunities

Objectives. We examined why older US adults without dental care coverage and use would have lower use rates if offered coverage than do those who currently have coverage.Methods. We used data from the 2008 Health and Retirement Study to estimate a multinomial logistic model to analyze the influence of personal characteristics in the grouping of older US adults into those with and those without dental care coverage and dental care use.Results. Compared with persons with no coverage and no dental care use, users of dental care with coverage were more likely to be younger, female, wealthier, college graduates, married, in excellent or very good health, and not missing all their permanent teeth.Conclusions. Providing dental care coverage to uninsured older US adults without use will not necessarily result in use rates similar to those with prior coverage and use. We have offered a model using modifiable factors that may help policy planners facilitate programs to increase dental care coverage uptake and use.According to 1 report, about 48% of adults with any private health insurance during 2000 had at least 1 dental visit, compared with about 29% of those with public health insurance and only 19% of those who were uninsured for the full year.1 The health insurance and dental care use association appears weak until one realizes that the insurance in question is actually medical insurance and not dental insurance. So, in fact, the reported rate is below that of other findings, which show that about 56% of adults with any private dental insurance had at least 1 dental visit, compared with about 22% of those who were uninsured for the full year.2 That there is any relationship between having medical insurance and seeking dental care at all is surprising because few medical insurance plans cover dental care services.3 Because medical insurance does not usually provide reimbursement for dental care, the medical insurance variable must represent some non–insurance-related unobserved health-seeking behavior that results in increased dental care use. However, several studies have examined the relationship between dental insurance coverage and dental care use, controlling for numerous socioeconomic and demographic variables.4–12 These studies show that, as expected, dental insurance is an important factor in the decision to seek and use dental services.Although the role of dental insurance coverage as a determinant of dental care use is now well established, less is known about the magnitude of its effect or how its effect may be modulated by other observed or unobserved factors. In 1 study, analysts measured the extent of the dental care coverage effect by analyzing Medical Expenditure Panel Survey data. Their results showed that the effect of dental care coverage is significant and increases the likelihood of a dental visit by 13%.13 A study examining Health and Retirement Study (HRS) data found that providing universal dental care coverage for an older US population would increase dental care use only 1% to 8% after applying a nonparametric approach to account for errors in measuring self-reported dental care coverage and unobserved factors for aversion to risk and future dental care needs (B. Kreider, J. Pepper, R. Manski, and J. Moeller, unpublished data, 2012). In this study the increase in dental care use was significant but not as large or far-reaching as initially expected. Although the analyses confirmed that dental care coverage increases the likelihood of dental care use, the results also suggested that the effect of providing dental care coverage on use may be surprisingly lower than expected.We have provided empirical evidence and a theoretical model to help explain why the effect of dental care coverage on use may be less than expected and to more fully describe dental care use in relation to dental care coverage and other relevant determinants of use. Our findings may help research analysts, program developers, and policy planners better understand problems associated with policies and programs designed to encourage greater use of dental care among the population.     

Dental Care Coverage and Use: Modeling Limitations and Opportunities

Objectives. We examined why older US adults without dental care coverage and use would have lower use rates if offered coverage than do those who currently have coverage.Methods. We used data from the 2008 Health and Retirement Study to estimate a multinomial logistic model to analyze the influence of personal characteristics in the grouping of older US adults into those with and those without dental care coverage and dental care use.Results. Compared with persons with no coverage and no dental care use, users of dental care with coverage were more likely to be younger, female, wealthier, college graduates, married, in excellent or very good health, and not missing all their permanent teeth.Conclusions. Providing dental care coverage to uninsured older US adults without use will not necessarily result in use rates similar to those with prior coverage and use. We have offered a model using modifiable factors that may help policy planners facilitate programs to increase dental care coverage uptake and use.According to 1 report, about 48% of adults with any private health insurance during 2000 had at least 1 dental visit, compared with about 29% of those with public health insurance and only 19% of those who were uninsured for the full year.1 The health insurance and dental care use association appears weak until one realizes that the insurance in question is actually medical insurance and not dental insurance. So, in fact, the reported rate is below that of other findings, which show that about 56% of adults with any private dental insurance had at least 1 dental visit, compared with about 22% of those who were uninsured for the full year.2 That there is any relationship between having medical insurance and seeking dental care at all is surprising because few medical insurance plans cover dental care services.3 Because medical insurance does not usually provide reimbursement for dental care, the medical insurance variable must represent some non–insurance-related unobserved health-seeking behavior that results in increased dental care use. However, several studies have examined the relationship between dental insurance coverage and dental care use, controlling for numerous socioeconomic and demographic variables.4–12 These studies show that, as expected, dental insurance is an important factor in the decision to seek and use dental services.Although the role of dental insurance coverage as a determinant of dental care use is now well established, less is known about the magnitude of its effect or how its effect may be modulated by other observed or unobserved factors. In 1 study, analysts measured the extent of the dental care coverage effect by analyzing Medical Expenditure Panel Survey data. Their results showed that the effect of dental care coverage is significant and increases the likelihood of a dental visit by 13%.13 A study examining Health and Retirement Study (HRS) data found that providing universal dental care coverage for an older US population would increase dental care use only 1% to 8% after applying a nonparametric approach to account for errors in measuring self-reported dental care coverage and unobserved factors for aversion to risk and future dental care needs (B. Kreider, J. Pepper, R. Manski, and J. Moeller, unpublished data, 2012). In this study the increase in dental care use was significant but not as large or far-reaching as initially expected. Although the analyses confirmed that dental care coverage increases the likelihood of dental care use, the results also suggested that the effect of providing dental care coverage on use may be surprisingly lower than expected.We have provided empirical evidence and a theoretical model to help explain why the effect of dental care coverage on use may be less than expected and to more fully describe dental care use in relation to dental care coverage and other relevant determinants of use. Our findings may help research analysts, program developers, and policy planners better understand problems associated with policies and programs designed to encourage greater use of dental care among the population.     

Immigrant children's reliance on public health insurance in the wake of immigration reform

Objectives. We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs.Methods. We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey.Results. Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured).Conclusions. In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.Recent attention has focused on immigrants’ use of public programs, especially health insurance programs, in the United States.^1–6 According to the 2000 census, 1 of every 5 children is a member of an immigrant family, and immigrants are increasingly dispersed across the country.⁷ Immigrant families are also complex in that parents and children may differ with respect to their immigration status. In 1998, 10% of children in the United States lived in “mixed-status” families composed of at least 1 noncitizen parent and at least 1 citizen child.⁸Because most children depend on their parents to obtain necessary benefits, including health insurance coverage, parental immigrant status may influence a child''s health insurance status and, ultimately, his or her health outcomes.⁹ As immigration rates continue to increase, these demographic shifts mean that the health of immigrant children will have a significant impact on the socioeconomic future of all Americans.Federal, state, and local policies can promote or hinder health insurance coverage for immigrants. The past 12 years have seen a pair of major policy changes designed to reduce immigrant enrollment in publicly funded health insurance programs. First, the Personal Responsibility Work Opportunity and Reconciliation Act of 1996 (commonly known as welfare reform) ruled that immigrants residing in the United States for less than 5 years were no longer eligible for any federally funded public benefits, including health insurance.¹⁰ In response, some states created public health insurance programs to cover immigrants with state funds.¹¹ Federal legislation to extend coverage to lawfully residing immigrant children continues to be debated.¹²Second, the “public charge” rule of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 was initially interpreted as requiring families to repay the US government for public benefits, including Medicaid, previously received at no cost.¹³ In response to collective advocacy efforts by health care providers and community-based organizations, the government specified in May 1999 that Medicaid benefits would be exempted from the public charge rule.¹⁴ In the wake of these rapid changes, there have been concerns about health care access for immigrant children, especially given that children require regular health supervision visits and immunizations to promote optimal health and well-being.^2,11,15–17Data from the mid-1990s have been used in most recent studies of health insurance coverage among immigrant children. One study involving data from the 1994 and 1996 versions of the Current Population Survey showed that 44.3% of immigrant children were privately insured, 34.1% were publicly insured, and 27.3% were uninsured.¹⁸ The majority of uninsured children had working parents whose employers failed to provide health insurance coverage or were members of families that did not meet Medicaid eligibility requirements for immigrants.¹⁸ Another study of low-income noncitizen adults and children showed that Medicaid participation rates dropped and that noncoverage rates increased between 1995 and 1998; these changes have been ascribed to confusion about eligibility rules for benefits related to welfare reform.¹⁵The most recent nationally representative analysis of which we are aware (from 1999) confirmed that foreign-born children (approximately 87% of whom were not US citizens⁷) were more likely to be uninsured than to have public health insurance coverage,¹⁹ but the data from that study were collected before the reversal of the public charge rule. In our study, we analyzed data from the 1997 through 2004 versions of the National Health Interview Survey (NHIS) in an effort to determine whether reversal of the public charge rule led to immigrant children becoming increasingly or decreasingly reliant on public health insurance programs.