Effects of state reinsurance programs on health insurance exchange premiums and insurer participation

Objective

The aim of the study was to estimate the effect of the state-based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation.

Data Source

2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets.

Study Design

An event study difference-in-differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year-by-year effects following program implementation.

Data Collection/Extraction Methods

Not applicable.

Principal Findings

Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%–13%, 5%–19%, and 11%–17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation.

Conclusion

State-based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation.     

Engaging Radiology Nurses in Quality Improvement Projects in a Women's Specialty Hospital

Measuring outcomes in health care have become mandatory as regulatory agencies, institutional guidelines, employers, and consumer groups advocate for quality health care focusing on improving patient outcomes. System-level quality departments often provide a framework for performance improvement (PI) that supports the organizational PI plan. However, nurses must learn to lead and be actively involved in projects in the radiology department to ensure key performance indicators are developed with on-the-ground quality management to improve patient outcomes, system performance, and professional development. This article explores such efforts at a large women’s specialty hospital in the Southern United States.     

Motivational interviewing for maternal Immunizations: Intervention development

Background and ObjectiveVaccine uptake during pregnancy remains low. Our objectives were to describe 1) development and adaptation of a clinician communication training intervention for maternal immunizations and 2) obstetrics and gynecology (ob-gyn) clinician and staff perspectives on the intervention and fit for the prenatal care context.MethodsDesign of the Motivational Interviewing for Maternal Immunizations (MI4MI) intervention was based on similar communication training interventions for pediatric settings and included presumptive initiation of vaccine recommendations (“You’re due for two vaccines today”) combined with motivational interviewing (MI) for hesitant patients. Interviews and focus group discussions were conducted with ob-gyn clinicians and staff in five Colorado clinics including settings with obstetric physicians, certified nurse midwives (CNMs), and clinician-trainees. Participants were asked about adapting training to the ob-gyn setting and their implementation experiences. Feedback was incorporated through iterative changes to training components.ResultsInterview and focus group discussion results from participants before (n = 3), during (n = 11) and after (n = 25) implementation guided intervention development and adaptation. Three virtual, asynchronous training components were created: a video and two interactive modules. This virtual format was favored due to challenges attending group meetings; however, participants noted opportunities to practice skills through role-play were lacking. Training modules were adapted to include common challenging vaccine conversations and live-action videos. Participants liked interactive training components and use of adult learning strategies. Some participants initially resisted the presumptive approach but later found it useful after applying it in their practices. Overall, participants reported that MI4MI training fit well with the prenatal context and recommended more inclusion of non-clinician staff.ConclusionsMI4MI training was viewed as relevant and useful for ob-gyn clinicians and staff. Suggestions included making training more interactive, and including more complex scenarios and non-clinician staff.     

Do social support and community engagement act as mechanisms in the association between neighbourhood income inequality and the mental health of mothers in Calgary,Canada? A mediation analysis

PurposeAccording to the social determinants of health framework, income inequality is a potential risk factor for adverse mental health. However, few studies have explored the mechanisms suspected to mediate this relationship. The current study addresses this gap through a mediation analysis to determine if social support and community engagement act as mediators linking neighbourhood income inequality to maternal anxiety and depressive symptoms within a cohort of new mothers living in the City of Calgary, Canada.MethodsData collected at three years postpartum from mothers belonging to the All Our Families (AOF) cohort were used in the current study. Maternal data were collected between 2012 and 2015 and linked to neighbourhood socioeconomic data from the 2006 Canadian Census. Income inequality was measured using Gini coefficients derived from 2006 after-tax census data. Generalized structural equation models were used to quantify the associations between income inequality and mental health symptoms, and to assess the potential direct and indirect mediating effects of maternal social support and community engagement.ResultsIncome inequality was not significantly associated with higher depressive symptoms (β = 0.32, 95%CI = −0.067, 0.70), anxiety symptoms (β = 0.11, 95%CI = −0.39, 0.60), or lower social support. Income inequality was not associated with community engagement. For the depression models, higher social support was significantly associated with lower depressive symptoms (β = −0.13, 95%CI = −0.15, −0.097), while community engagement was not significantly associated with depressive symptoms (β = 0.059, 95%CI = −0.15, 0.27). Similarly, for the anxiety models, lower anxiety symptoms were significantly associated with higher levels of social support (β = −0.17, 95%CI = −0.20, −0.13) but not with higher levels of community engagement (β = 0.14, 95%CI = −0.14, 0.41).ConclusionThe current study did not find clear evidence for social support or community engagement mediating the relationship between neighbourhood income inequality and maternal mental health. Future investigations should employ a broader longitudinal approach to capture changes in income inequality, potential mediators, and mental health symptomatology over time.     

Whose place? Lessons from a case study of a guardianship determination for an Australian Indigenous child

Whose values matter when considering which environment is healthier for a child whose guardianship is contested? The biological mother from a remote Australian Aboriginal community, who voluntarily relinquished her but has now requested her return? The foster mother who has cared for her in a metropolitan centre in another State of Australia, thousands of kilometres away? The welfare professionals who also live in that city? Or the child herself, who left her birth home and community five years earlier at the age of two? Drawing on a case study of a seven-year old Aboriginal girl, the authors argue that non-Indigenous values trumped Indigenous values without the realisation of key players who were empowered to make such determinations. The article uses Manuel DeLanda's neo-assemblage theory to consider the range of processes that exert themselves to shape place-values and social identity in colonised nations. It will also draw on Erik Erikson's and Lev Vygotsky's theories of psychosocial development to consider competing sets of values that raised feelings of dissonance within the child. Beliefs about what makes a place health-giving are revealed to be complex in colonised nations. Despite policy and legislative changes to better support Aboriginal people and their right to difference, non-Indigenous professionals can continue to be driven by an unrecognised systemic racism. While place-values are not, of course, the only (or perhaps even the most significant) consideration in guardianship determinations, this article will argue they can play a significant and covert role.     

Climate Change: Effects on the Older Adult

The effects of climate change include floods, hurricanes, heat waves, and fires; these natural disasters can result in respiratory, cardiovascular, and psychological harm in older adults, who experience the highest morbidity and mortality during heat waves. Advanced practice registered nurses (APRNs) need education on preparing, assessing, and treating older adults for climate-change disasters, especially heat waves. This article will help APRNs understand the effects of climate-change events on the vulnerable older adults and advocates for the need to integrate health effects of climate change into curricula, practicums, policy, and research agendas.     

Burnout and the Sexual Assault Nurse Examiner: Who Is Experiencing Burnout and Why?

IntroductionA sexual assault nurse examiner role exemplifies the high-stress and highly emotional patient interactions that are often associated with burnout. The purpose of this study was to examine the frequency of burnout among sexual assault nurse examiners in North Carolina.MethodsThis cross-sectional study was an anonymous survey of practicing sexual assault nurse examiners within North Carolina using the Maslach Burnout Inventory and additional demographics. Results were analyzed with odds ratios, confidence intervals, Fisher exact, chi-square, and Kruskal Wallis tests as appropriate.ResultsAmong 95 respondents, burnout was more frequent in sexual assault nurse examiners who stopped both emergency and nurse examiner work (55.6%, odds ratio 4.41, 95% confidence interval 1.07-18.06) and in dual function nurses (both emergency and nurse examiner work, 35.7%, odds ratio 2.71, 95% confidence interval 1.04-7.06). Sexual assault nurse examiners who had a high percentage of pediatric cases (above the median of 40%) were more likely to meet burnout thresholds for emotional exhaustion scores > 26 (48.78% vs 25.93%, χ² = 5.30, P = .02) and more likely to meet burnout thresholds for depersonalization scores > 9 (48.78% vs 24.07%, χ² = 6.28, P = .01).DiscussionHigher frequency of burnout threshold criteria was found in those people who worked concurrently as a sexual assault nurse examiner and an emergency nurse and in those who had retired from both specialties. We also found that sexual assault nurse examiners with a higher case mix of pediatric cases had higher emotional exhaustion scores and higher depersonalization scores.