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.     

Medicaid Coverage and Medical Interventions During Pregnancy

This paper extends prior research on the effect of Medicaid coverage on medical interventions during pregnancy (prenatal ultrasound) and birth (ultrasound during delivery, cesarean delivery, inducement, and fetal monitor). The data are from two sources: the New York State Vital Statistics (VS) matched infant birth-death file and the Statewide Planning and Research Cooperative System (SPARCS) file for 1993–1996. Medicaid coverage increases the likelihood of teens and adults receiving prenatal care relative to being uninsured. Overall, the effect of insurance type varies depending on whether the procedure is part of standard care (ultrasound and fetal monitor) or more likely to be elective (inducement and cesarean delivery). Insurance type has a greater effect for elective procedures than for procedures that are part of standard care.JEL classification: I1This research was completed while I was performing post-doctoral work at SUNY – Binghamton. The opinions in this paper are the authors’ and do not represent those of the Centers for Medicare & Medicaid Services.     

国际医疗救助费用控制实践及启示

分析了国际医疗保险费用控制趋势,阐述了不同筹资体系的国家医疗保险背景及医疗救助费用控制实践,提出了控制我国医疗救助费用的相关政策建议:确定救助对象的资格认定程序,发展完善社区卫生服务,加强预防保健,改革费用支付和分担方式及加快医疗救助法制建设。     

从医药消费量的时序变化看医疗改革效果

文章使用经价格指数调整后的医疗保健支出作为医药消费量的代理变量,以城镇居民医药消费量的时序变化为评价指标,建立计量模型,采用最小二乘法,对1997—2005年30个省的相关数据进行回归分析,得出医药消费量的时序变化。发现在保证其他因素不变后,居民人均医药消费量在大部分年度不但没有增加反而下降的事实,证明医疗体制改革没有达到预期效果。最后本文建议医疗体制改革设计要从根本入手,要考虑到具体措施的可操作性。     

The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment

Policy Points:

• We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression.
• Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40%.
• There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.

Context

Expanding Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression, but the ways that Medicaid affects mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression remain unclear.

Methods

We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage using a randomized‐controlled design, drawing on both primary and administrative data sources.

Findings

Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40%. The share of respondents screening positive for depression dropped by 9.2 percentage points overall, and by 13.1 for those with preexisting depression diagnoses, with greatest relief in symptoms seen primarily in feeling down or hopeless, feeling tired, and trouble sleeping—consistent with the increase observed not just in medications targeting depression but also in those targeting sleep.

Conclusions

Medicaid coverage had significant effects on the diagnosis, treatment, and outcomes of a population with substantial unmet mental health needs. Coverage increased access to care, reduced the prevalence of untreated and undiagnosed depression, and substantially improved the symptoms of depression. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.     

社会医疗保险的医疗费用函数建模分析

由于疾病发生的随机性、医学技术进步和道德风险的影响,社会医疗保险在医疗费用的精算上存在着很大困难。以我国社会医疗保险患者中336万余次实际就诊记录的大样本数据资料为基础,通过显著性因子检验,建立了以工资收入、相对医疗费用指数、职工类别和性别为参数的医疗费用函数多元回归对数线性模型,并成功地应用于社会医疗保险基金运行过程的仿真分析之中,对于社会医疗保险的管理与决策具有重要的价值。     

论发展我国的医疗救助制度

从医疗救助的理论与实践基础入手,从举办主体、救助对象、救助对象资格认定、管理模式、资金筹集渠道、费用支付方式诸角度论述了发展与我国国情相适应的医疗救助制度,指出发展医疗救助制度对于完善我国社会福利体系、促进人口发展与社会进步的意义,提出了在医疗救助中引入市场机制的设想,并指出了重点疾病干预对于医疗救助的重要性。     

Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low‐Income Adults with Behavioral Health Conditions

Objective

To examine the effect of Medicaid expansions on health insurance coverage and access to care among low‐income adults with behavioral health conditions.

Data Sources/Study Setting

Nine years (2004–2012) of individual‐level cross‐sectional data from a restricted‐access version of National Survey on Drug Use and Health.

Study Design

A quasi‐experimental difference‐in‐differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low‐income adults under the Section §1115 waiver with those residing in the rest of the country.

Data Collection/Extraction Methods

The analytic sample includes low‐income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low‐income adults have past‐year serious psychological distress and 24,900 low‐income adults have a past‐year substance use disorder (SUD).

Principal Findings

Among low‐income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p < .05), a reduction in the probability of perceiving an unmet need for mental health (MH) treatment (p < .05) and for SUD treatment (p < .05), as well as an increase in the probability of receiving MH treatment (p < .01).

Conclusions

The ongoing implementation of Medicaid expansions has the potential to improve health insurance coverage and access to care for low‐income adults with behavioral health conditions.     

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.     

The Impacts of China's Urban Employee Basic Medical Insurance on Healthcare Expenditures and Health Outcomes

At the end of 1998, China launched a government‐run mandatory insurance program, the urban employee basic medical insurance (UEBMI), to replace the previous medical insurance system. Using the UEBMI reform in China as a natural experiment, this study identifies variations in patient cost sharing that were imposed by the UEBMI reform and examines their effects on the demand for healthcare services. Using data from the 1991–2006 waves of the China Health and Nutrition Survey, we find that increased cost sharing is associated with decreased outpatient medical care utilization and expenditures but not with decreased inpatient care utilization and expenditures. Patients from low‐income and middle‐income households or with less severe medical conditions are more sensitive to prices. We observe little impact on patient's health, as measured by self‐reported health status. Copyright © 2015 John Wiley & Sons, Ltd.     

A Statewide Assessment of Tuberculin Skin Testing of Preschool Children Enrolled in Medicaid Managed Care

Objectives: This study examined tuberculosis screening among preschool children enrolled in a statewide Medicaid managed care program. Methods: A random sample of 2,000 was selected from 19 to 35 month old children who were continuously enrolled in Rhode Island's Medicaid managed care program for 1 year. Sociodemographic data were obtained from computerized administrative databases. Medical record audits were performed to obtain the dates and results of tuberculosis tests. Results: Data from the medical record audits were available for 1,988 of the study children. For 1,215 of the study children (1,215/1,988=61%) a tuberculin skin test had been performed, but a reading was only documented for 736 children (60% of children who received a tuberculin skin test) and only one child tested positive (0.1%). Conclusions: A majority of preschool children in this population in which the prevalence of risk factors for tuberculosis is likely to be relatively high did have a tuberculosis test performed. However, in many cases the tuberculin skin test was either not read or the results not documented. The low rate of positivity is consistent with current AAP guidelines for selective tuberculin skin testing.     

上海市闵行区外来人口卫生服务研究

为了解上海市外来人口的健康状况、卫生服务利用和医疗保障情况,本课题组通过问卷和焦点组访谈的形式对闵行区外来人口进行了调查。调查结果显示,97．24%的外来人口自觉身体状况良好,其两周患病率(23．48‰)、住院率(0．83％)、慢性病患病率(42‰)均低于全国平均水平；同时由于文化程度低、经济水平差、流动性强等原因,外来人口中存在着医疗保险覆盖率低、对卫生服务利用较少、对社区卫生服务中心知晓程度不高、公共卫生服务难以实施等问题。针对调研结果提出一些应对思路,建议政府在制定政策时尽量向外来人口倾斜,卫生部门与其他各部门联动起来做好外来人口的卫生服务工作,并加大教育宣传力度,转变外来人口的健康意识,提高外来人口的健康水平。     

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995–2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.     

The Effect of Medicaid Managed Care on Rural Public Health Departments

Medicaid managed care programs are now operating in more than half of all rural counties in the United States. This study examines how rural health departments that have historically provided clinical services have responded to and been affected by the implementation of Medicaid managed care. To the extent that rural health departments have changed, the effect of this change on the health department and the rural populations that these providers serve is assessed. Site visits were made to four rural public health departments in each of five study states, for a total of 20 case studies. At each site, in-person interviews of county public health department directors were conducted using semistructured interview protocols. In recent years, the majority of health departments decreased or discontinued provision of well-child services, causing many to lose Medicaid revenue. None of the health departments appeared to be in danger of closing, but most lost income security. Medicaid managed care appeared to have increased the number of children with medical homes in the private sector, but adequacy and continuity of care remains an issue. Privatizing Medicaid managed care has not decreased fragmentation, as public health functions such as tracking and screening represent an important facet of comprehensive health services for poor rural populations.     

医疗保险与卫生服务发展研究

医疗保险与卫生服务是辩证统一的关系。医疗保险的推行,对医疗机构既是挑战也是机遇,要求医疗机构转变观念,增强竞争意识和竞争能力,做好监督控制、审核评价工作。成本核算、定额补偿是医院乃至医疗保险发展的核心问题。医疗保险制度的建立和完善有助于优化卫生资源配置,完善医院内部科学管埋体制,提高医疗质量,促进医院发展。社区卫生服务应纳入医疗保险范畴,医疗保险管理邯门从效率角度出发,也应首先选择社区卫生服务机构承担医疗保险任务。社区卫生服务的发展对医疗保障体系的建立和完善将起到重要的推进作用,而医疗保障体系的建立,必将促进社区卫生服务的深入发展。