Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

Research Objective

To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent''s private health plan. Nearly one-in-three young adults lacked coverage before the ACA.

Study Design, Methods, and Data

Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.

Principal Findings

This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.

Conclusions and Implications

ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.     

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.     

Medicare Home Health Care Patient Case-Mix Before and After the Balanced Budget Act of 1997: Effect on Dual Eligible Beneficiaries

The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. We used Medical Expenditure Panel Survey data to assess the impact of the BBA on Medicare HHC patient case-mix measured by the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. There was a significant increase in Medicare HHC patient case-mix between the pre-BBA and Prospective Payment System (PPS) periods. The increase in the standardized-predicted risk score from the Interim Payment System period to PPS was nearly 4 times greater for the dual eligibles (Medicare-Medicaid) than for the Medicare-only population. This significantly greater rise in the HHC resources required by dual eligibles as compared to nonduals could be due to a shift in HHC payers from Medicare only to Medicaid rather than be an actual increase in case-mix per se.     

Opportunities for social work under the Affordable Care Act: A call for action

The Affordable Care Act (ACA) has profoundly restructured American health care. Numerous social work authors have commented on the importance of the ACA’s reforms to social work practice, education, and research. This article summarizes the literature, adds relevant information, and makes recommendations for future actions. The policy, opinion, and peer-reviewed literatures were systematically reviewed. Sixty-three publications appeared between 2010 and 2015 are included. Five themes emerged, as follows: 1) the crucial provisions of the ACA, 2) the natural affinity of social work and the ACA reforms, 3) curricular adaptations needed to address changing workforce needs, 4) areas for continued social work advocacy, and 5) opportunities for high-impact social work research. This article provides a comprehensive introduction to the ACA, its reforms, and opportunities for social work to assume a high visibility leadership role in implementing the reforms, with particular emphasis on needed curricular changes and opportunities for research.     

Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries

PURPOSE

Under health care reform, states will have the opportunity to expand Medicaid to millions of uninsured US adults. Information regarding this population is vital to physicians as they prepare for more patients with coverage. Our objective was to describe demographic and health characteristics of potentially eligible Medicaid beneficiaries.

METHODS

We performed a cross-sectional study using data from the National Health and Nutrition Examination Survey (2007–2010) to identify and compare adult US citizens potentially eligible for Medicaid under provisions of the Patient Protection and Affordable Care Act (ACA) with current adult Medicaid beneficiaries. We compared demographic characteristics (age, sex, race/ethnicity, education) and health measures (self-reported health status; measured body mass index, hemoglobin A_1c level, systolic and diastolic blood pressure, depression screen [9-item Patient Health Questionnaire], tobacco smoking, and alcohol use).

RESULTS

Analyses were based on an estimated 13.8 million current adult non-elderly Medicaid beneficiaries and 13.6 million nonelderly adults potentially eligible for Medicaid. Potentially eligible individuals are expected to be more likely male (49.2% potentially eligible vs 33.3% current beneficiaries; P <.001), to be more likely white and less likely black (58.8% white, 20.0% black vs 49.9% white, 25.2% black; P = .02), and to be statistically indistinguishable in terms of educational attainment. Overall, potentially eligible adults are expected to have better health status (34.8% “excellent” or “very good,” 40.4% “good”) than current beneficiaries (33.5% “excellent” or “very good,” 31.6% “good”; P <.001). The proportions obese (34.5% vs 42.9%; P = .008) and with depression (15.5% vs 22.3%; P = .003) among potentially eligible individuals are significantly lower than those for current beneficiaries, while there are no significant differences in the expected prevalence of diabetes or hypertension. Current tobacco smoking (49.2% vs 38.0%; P = .002), and moderate and heavier alcohol use (21.6% vs 16.0% and 16.5% vs 9.8%; P <.001, respectively) are more common among the potentially eligible population than among current beneficiaries.

CONCLUSIONS

Under the ACA, physicians can anticipate a potentially eligible Medicaid population with equal if not better current health status and lower prevalence of obesity and depression than current Medicaid beneficiaries. Federal Medicaid expenditures for newly covered beneficiaries therefore may not be as high as anticipated in the short term. Given the higher prevalence of tobacco smoking and alcohol use, however, broad enrollment and engagement of this potentially eligible population is needed to address their higher prevalence of modifiable risk factors for future chronic disease.     

Oral Motor Feeding in the Neonatal Intensive Care Unit: Exploring Perceptions of Parents and Occupational Therapists

The purpose of this qualitative study was to explore the perceptions of three occupational therapists and three parents regarding occupational therapy services provided in the neonatal intensive care unit. Data were obtained through participant interviews. Role of the occupational therapist, parent training, and time spent with parents were themes that emerged from the therapist interviews. Themes from the parent interviews included occupational therapy intervention and treatment, time spent with occupational therapist, and perceptions. A cross-case analysis addressed two common themes: amount of time spent in parent training and perceptions of training provided. Implications for occupational therapy practice in the neonatal intensive care unit are discussed.     

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.     

The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

Objective

To assess the impact of the Patient Protection and Affordable Care Act''s (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.

Data Sources

Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010–2011.

Study Design

We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.

Principal Findings

Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.

Conclusions

The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.     

Providing Health Information to Latino Farmworkers: The Case of the Affordable Care Act

Objective: Providing health program information to vulnerable communities, such as Latino farmworkers, is difficult. This analysis describes the manner in which farmworkers receive information about the Affordable Care Act, comparing farmworkers with other Latinos. Methods: Interviews were conducted with 100 Latino farmworkers and 100 urban Latino North Carolina residents in 2015. Results: Most farmworkers had received health information from a community organization. Trusted sources for health information were health care providers and community organizations. Sources that would influence decisions to enroll were Latino nurses and doctors, religious leaders, and family members. Traditional media, including oral presentation and printed material at the doctor’s office, were preferred by the majority of farmworkers and non-farmworkers. Farmworkers used traditional electronic media: radio, television, and telephone. More non-farmworkers used current electronic media: e-mail and Internet. Conclusions: Latino farmworkers and non-farmworkers prefer traditional media in the context of a health care setting. They are willing to try contemporary electronic media for this information.     

Occupational Therapy in the Intensive Care Unit: A Systematic Review

This paper is a synthesis of the available literature on occupational therapy interventions performed in the adult intensive care unit (ICU). The databases of Ovid MEDLINE, Embase, the Cochrane Library, ClinicalTrials.gov and CINAHL databases were systematically searched from inception through August 2016 for studies of adults who received occupational therapy interventions in the ICU. Of 1,938 citations reviewed, 10 studies met inclusion criteria. Only one study explicitly discussed occupational therapy interventions performed and only one study specifically tested the efficacy of occupational therapy. Future research is needed to clarify the specific interventions and role of occupational therapy in the ICU and the efficacy of these interventions.     

The Careers of Occupational Therapists Five Years After Graduation: Modified Plans But Satisfying Lives

The fourth survey in a longitudinal study of occupational therapists' career patterns elicited a 66% response rate (N = 49). The percentage employed in the profession had fallen by 21.5% since 1980. Less than half of the 22.4% who were unemployed planned to return to professional work. Job satisfaction remained high among the employed though work values had changed. Pay, job security, chances for promotion and respect received were considered more important than in 1980. The most stressful aspects of work had altered with work pressure and worries about patients being the most stressful. While 53% regarded themselves as specialists, areas of speciality differed from those planned earlier. Some had been promoted (40%), but few had high status ambitions. Many therapists (63%) had married and 24% had children. Most mothers of young children were unemployed. The number of children desired had decreased. There was little evidence of role conflict and therapists were satisfied with most areas of their lives.     

北京市大兴区2009年职业卫生检测及职工健康监护分析

目的了解北京市大兴区职工接触职业病危害因素情况和用人单位职业病危害现状。方法对2009年72家企业作业场所的职业病危害因素检测情况及233家用人单位的7735名职工职业健康检查结果进行分析。结果按企业所属性质分类,联营企业样品合格率低于其余经济类型企业的样品合格率。按职业病危害因素性质分类,物理因素、粉尘因素样品合格率远低于化学因素样品合格率。检出听力损失296人,发生率为13.5%(296/2200);白细胞低于正常值216人,发生率为7.42%(216/2910),二者发生率差异有统计学意义(χ2=50.56,P0.01)。结论受检单位职业病危害因素以噪声为主,加强对噪声的治理和加强职业健康监护是今后职业卫生工作的重点。同时应加大对联营企业存在的职业病危害因素的检测力度,加强对物理因素、粉尘职业病危害因素的检测。     

Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison

Purpose

Rural young adults experience greater unmet need for mental health (MH) and alcohol or drug (AOD) treatment and lower health insurance coverage than urban residents. It is unknown whether Affordable Care Act (ACA) reforms in 2010 (dependent coverage extended to age 26) or 2014 (Medicaid expansion) closed rural/urban gaps in insurance and treatment. The present study compared changes in rates of health insurance, MH treatment, and AOD treatment for rural and urban young adults over a period of ACA reforms.

Methods

Young adult participants (18‐25 years) in the National Survey on Drug Use and Health (2008‐2014) with past‐year psychological distress or AOD abuse were included. Difference‐in‐differences logistic regression models estimated rural/urban differences in insurance, MH, and AOD treatment pre‐ versus post‐ACA reforms. Analyses adjusted for gender, race, marital status, and health status.

Results

Among 39,482 young adults with psychological distress or AOD, adjusted insurance rates increased from 72.0% to 81.9% (2008‐2014), but a significant rural/urban difference (5.1%) remained in 2014 (P < .05). Among young adults with psychological distress (n = 23,470), MH treatment rates increased following 2010 reforms from 30.2% to 33.0%, but gains did not continue through 2014. Differences in MH treatment over time did not vary by rural/urban status and there were no significant changes in AOD treatment for either group.

Conclusions

Although rates of insurance increased for all young adults, a significant rural/urban difference persisted in 2014. Meaningful increases in MH and AOD treatment may require targeted efforts to reduce noninsurance barriers to treatment.