How the Affordable Care Act and Mental Health Parity and Addiction Equity Act Greatly Expand Coverage of Behavioral Health Care

The Patient Protection and Affordable Care Act (ACA) will expand coverage of mental health and substance use disorder benefits and federal parity protections to over 60 million Americans. The key to this expansion is the essential health benefit provision in the ACA that requires coverage of mental health and substance use disorder services at parity with general medical benefits. Other ACA provisions that should improve access to treatment include requirements on network adequacy, dependent coverage up to age 26, preventive services, and prohibitions on annual and lifetime limits and preexisting exclusions. The ACA offers states flexibility in expanding Medicaid (primarily to childless adults, not generally eligible previously) to cover supportive services needed by those with significant behavioral health conditions in addition to basic benefits at parity. Through these various new requirements, the ACA in conjunction with Mental Health Parity and Addiction Equity Act (MHPAEA) will expand coverage of behavioral health care by historic proportions.     

Premium subsidies,the mandate,and Medicaid expansion: Coverage effects of the Affordable Care Act

Using premium subsidies for private coverage, an individual mandate, and Medicaid expansion, the Affordable Care Act (ACA) has increased insurance coverage. We provide the first comprehensive assessment of these provisions’ effects, using the 2012–2015 American Community Survey and a triple-difference estimation strategy that exploits variation by income, geography, and time. Overall, our model explains 60% of the coverage gains in 2014–2015. We find that coverage was moderately responsive to price subsidies, with larger gains in state-based insurance exchanges than the federal exchange. The individual mandate's exemptions and penalties had little impact on coverage rates. The law increased Medicaid among individuals gaining eligibility under the ACA and among previously-eligible populations (“woodwork effect”) even in non-expansion states, with no resulting reductions in private insurance. Overall, exchange premium subsidies produced 40% of the coverage gains explained by our ACA policy measures, and Medicaid the other 60%, of which 1/2 occurred among previously-eligible individuals.     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

Redressing the Limitations of the Affordable Care Act for Mexican Immigrants Through Bi-National Health Insurance: A Willingness to Pay Study in Los Angeles

The 12.4 million Mexican migrants in the United States (US) face considerable barriers to access health care, with 45 % of them being uninsured. The Affordable Care Act (ACA) does not address lack of insurance for some immigrants, and the excluded groups are a large proportion of the Mexican–American community. To redress this, innovative forms of health insurance coverage have to be explored. This study analyses factors associated with willingness to pay for cross-border, bi-national health insurance (BHI) among Mexican immigrants in the US. Surveys were administered to 1,335 Mexican migrants in the Mexican Consulate of Los Angeles to assess their health status, healthcare utilization, and willingness to purchase BHI. Logistic regression was used to identify predictors of willingness to pay for BHI. Having a job, not having health insurance in the US, and relatives in Mexico attending public health services were significant predictors of willingness to pay for BHI. In addition, individuals identified quality as the most important factor when considering BHI. In spite of the interest for BHI among 54 % of the sampled population, our study concludes that this type of coverage is unlikely to solve access to care challenges due to ACA eligibility among different Mexican immigrant populations.     

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X–Funded Facilities in 2016

CONTEXT

As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X–funded facilities under ACA guidelines is essential to understanding what is at stake.

METHODS

A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X–funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi‐square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types.

RESULTS

Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign‐born clients were less likely than U.S.‐born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one‐quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out.

CONCLUSION

Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.     

Do individuals respond to cost-sharing subsidies in their selections of marketplace health insurance plans?

The Affordable Care Act (ACA) provides assistance to low-income consumers through both premium subsidies and cost-sharing reductions (CSRs). Low-income consumers’ lack of health insurance literacy or information regarding CSRs may lead them to not take-up CSR benefits for which they are eligible. We use administrative data from 2014 to 2016 on roughly 22 million health insurance plan choices of low-income individuals enrolled in ACA Marketplace coverage to assess whether they behave in a manner consistent with being aware of the availability of CSRs. We take advantage of discontinuous changes in the schedule of CSR benefits to show that consumers are highly sensitive to the value of CSRs when selecting insurance plans and that a very low percentage select dominated plans. These findings suggest that CSR subsidies are salient to consumers and that the program is well designed to account for any lack of health insurance literacy among the low-income population it serves.     

Underinsurance for Recently Recommended Vaccines in Private Health Plans

Underinsurance for vaccines presents financial barriers to vaccination. Preventive services coverage is of interest in national healthcare reform. To assess vaccine benefits coverage in private health plans. Private health insurance carriers were surveyed December 2008–June 2009 on policies regarding vaccine coverage in fully insured plans. Carriers were identified as multi-state, state-specific Blue Cross or local-independent carriers. Plan types included HMO, PPO, POS and ‘other.’ Full benefits coverage was defined as having benefits without a copay or coinsurance for a recommended vaccine. Analyses were conducted to examine associations between carrier type, plan type, and full benefits coverage. Fifty-one carriers (response rate?=?56?%) provided data for 78 unique plans, reflecting over 47 million private plan enrollees. Full benefits coverage was highest for combined tetanus/diphtheria/acellular pertussis (74?%) and lower for pneumococcal conjugate (72?%), rotavirus (72?%), human papillomavirus (71?%), hepatitis A (68?%), meningococcal conjugate (67?%), inactivated influenza (67?%), live attenuated influenza (63?%) and zoster (57?%) vaccines. Compared with plans offered by state-specific Blue Cross carriers, significantly higher proportions of multi-state carriers and local independent carriers had plans with full benefits coverage for vaccines (p?<?0.05). Compared with PPO and “other” plans, significantly higher proportions of HMO and POS plans had full benefits coverage for vaccines (p?<?0.05). In this national study, levels of underinsurance for immunization leave room for improvement. State-specific Blue Cross plans and indemnity or high-deductible plans are least likely to offer full coverage for recently recommended vaccines, and may face changes with incorporation of “essential health benefits” requirements.     

Why Uninsured Free Clinic Patients Don’t Apply for Affordable Care Act Health Insurance in a Non-expanding Medicaid State

Even after the introduction of the Patient Protection and Affordable Care Act (ACA), uninsured visits remain high, especially in states that opted out of Medicaid expansion. Since the ACA does not provide universal coverage, free clinics serve as safety nets for the un- or under-insured, and will likely continue serving underserved populations. The purpose of this study is to examine factors influencing intentions to not apply for health insurance via the ACA among uninsured free clinic patients in a state not expanding Medicaid. Uninsured primary care patients utilizing a free clinic (N = 551) completed a self-administered survey in May and June 2015. Difficulty obtaining information, lack of instruction to apply, and cost, are major factors influencing intention not to apply for health insurance through the ACA. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of perceived barriers to applying for health insurance through the ACA. Age is an important factor impacting individuals’ intentions not to apply for health insurance through the ACA, as older patients in particular need assistance to obtain relevant information about the ACA and other resources. A number of unchangeable factors limit the free clinics’ ability to promote enrollment of health insurance through the ACA. Yet free clinics could be able to provide some educational programs or the information of resources to patients. In particular, non-US born English speakers, Spanish speakers, and older adults need specific assistance to better understand health insurance options available to them.     

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.     

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.     

The Affordable Care Act's insurance market regulations' effect on coverage

Much of the debate surrounding reform of the Patient Protection and Affordable Care Act (ACA) revolves around its insurance market regulation. This paper studies the impact on health insurance coverage of those provisions. Using data from the American Community Survey, years 2008–2015, I focus on individuals, ages 26 to 64, who are ineligible for the subsidies or Medicaid expansions included in the ACA to isolate the effect of its market regulation. To account for time trends, I utilize a differences‐in‐differences approach with a control group of residents of Massachusetts who were already subject to a similarly regulated health insurance market. I find that the ACA's regulations caused an increase of 0.95 percentage points in health insurance coverage for my sample in 2014. This increase was concentrated among younger individuals, suggesting that the law's regulations ameliorated adverse selection in the individual health insurance market.     

Avoiding health insurance crowd-out: evidence from the Medicare as secondary payer legislation

The cost of expanding health insurance coverage increases when people who would otherwise purchase insurance obtain public coverage. This paper investigates the effects of one of the first efforts to target insurance benefits to the most needy, the 1982 medicare as secondary payer (MSP) provisions. We find strong evidence of low compliance with the MSP both in terms of medical bill payments (payment compliance) and employer-sponsored insurance coverage (coverage compliance). We estimate payer compliance at approximately 33%. Coverage compliance is lower, at under 25%. We find weak evidence that the MSP caused older workers to shift toward MSP-exempt jobs.     

Health insurance and opioid deaths: Evidence from the Affordable Care Act young adult provision

The concurrence of health insurance expansion under the Affordable Care Act (ACA) and increasing opioid‐related mortality has led to debate whether insurance increases or decreases opioid deaths. I use the introduction of the ACA young adult (YA) provision as a quasi‐experiment and utilize the resulting policy‐induced variation across states over time in YA access to insurance to study the effect of coverage on opioid‐related mortality. I rely on the share of state populations which stood to gain insurance before the ACA to perform a dose–response analysis, and find that the YA provision reduced opioid‐related mortality. The analysis suggests that 1 percentage point more coverage reduced opioid mortality among YA by 2.5/100,000 or 19.8%.     

Reducing Ex-offender Health Disparities through the Affordable Care Act: Fostering Improved Health Care Access and Linkages to Integrated Care

Despite steadily declining incarceration rates overall, racial and ethnic minorities, namely African Americans, Latinos, and American Indians and Alaska Natives, continue to be disproportionately represented in the justice system. Ex-offenders commonly reenter communities with pressing health conditions but encounter obstacles to accessing care and remaining in care. The lack of health insurance coverage and medical treatment emerge as the some of the most reported reentry health needs and may contribute to observed health disparities. Linking ex-offenders to care and services upon release increases the likelihood that they will remain in care and practice successful disease management. The Affordable Care Act (ACA) offers opportunities to address health disparities experienced by the reentry population that places them at risk for negative health outcomes and recidivism. Coordinated efforts to link ex-offenders with these newly available opportunities may result in a trajectory for positive health and overall well-being as they reintegrate into society.     

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.     

The Philippines' National Health Insurance Act: a German perspective

Through the recent National Health Insurance Act (NHIA), the Philippines have committed themselves to introducing a social health insurance with universal coverage within 15 years. Germany was the first country to introduce a social health insurance system more than 100 years ago. Its system is based on the principles of corporatism, federalism and a mandate for equity. Based on a long-term German experience with equity, quality, cost and efficiency issues, the Philippines' NHIA is analysed concerning the entitlement to benefits and the benefit package, the organization of the health insurance programme, health insurance financing, and provider payment mechanisms. It is suggested that the Philippines could profit from including preventive and promotive services as well as pharmaceuticals in the benefits package. The organization of the health insurance system could be decentralized using the 13 regions as its principal units. To achieve financial equity between regions and health funds, a contribution compensation scheme is proposed. To prevent over-utilization in over-served areas and to promote utilization in under-served areas, a relative value scale for fee-for-service payments seem advisable.     

Women’s Health and the Affordable Care Act: High Hopes Versus Harsh Realities?

Our population-based survey of 1078 randomly sampled US women, aged 18 to 55 years, sought to characterize their understanding of and attitudes toward the Affordable Care Act (ACA). Most women, especially socially disadvantaged groups, had negative or uncertain attitudes toward the ACA and limited understanding of its health benefits, including its relevance for their own health service coverage and utilization. Our findings are important for continued research, policy, and practice, with implications for whether, when, and how improved coverage will translate to improved access and outcomes for US women.Women’s health clinicians, researchers, and policymakers are hopeful that expanding health care coverage under the Patient Protection and Affordable Care Act (ACA)1 will improve the health of US women. By requiring coverage, increasing access to affordable health plans, incentivizing utilization of high-value services, establishing benefit mandates, and reducing cost sharing, the ACA is expected to improve health outcomes and reduce health disparities for women. Since ACA implementation began, however, it has become clear that the public’s participation in its programs and benefits is compromised by widespread confusion.2–6 Recognizing that the ACA can only have an impact on women’s health (individual and population) if women are aware of available benefits and act upon them,7–9 we conducted a study to examine women’s understanding of and attitudes toward the ACA. Specifically, we sought to determine (1) whether women were aware and approved of the ACA and the women’s health benefits attributable to it, (2) whether women expected their coverage of women’s health services and subsequent service utilization to change as a result of the ACA, and (3) whether women’s awareness and attitudes differed across sociodemographic groups.     

Selection in employer sponsored health insurance

This paper examines the extensive margin of selection into employer-sponsored health insurance (ESHI) using data from the Medical Expenditures Panel Survey 2001–2010 and 2014–2016 and the National Longitudinal Survey of Youth’97 in 2010. Controlling for a large set of firm and job characteristics, I find that before the implementation of the Affordable Care Act (ACA) in 2014, workers aged 25–40 who declined ESHI and remained privately uninsured had significantly higher health risk than those who enrolled. No correlation between health and insurance take-up is found in the 41–64 age group. These results are partly explained by differences in income and Medicaid crowding out ESHI for high risk workers. The paper sheds light on the characteristics of uninsured workers, their incentives for declining insurance and the interaction between private and public health insurance. The allocation of ESHI remained unchanged after the ACA was introduced due to the provisions’ counteracting effects.