The US Affordable Care Act: Reflections and directions at the close of a decade

Factors associated with the enrollment of commercial medical insurance in China: Results from China General Social Survey

BACKGROUND

The Chinese government has been promoting commercial medical insurance (CMI) in recent decades as it plays an increasingly important role in addressing disease burden, health inequities, and other healthcare challenges. However, compared with developed countries, the CMI is still less fledged with low coverage.

OBJECTIVE

This study aims to explore the factors associated with enrollment in CMI, with regards to explicit characteristics (including sociodemographic characteristics and family economic status), latent characteristics (including social security status), and the global incentive compatibility index (including health status), to inform the design of CMI to improve its coverage in China.

METHODS

Based on the principal-agent model, we summarized and classified the factors associated with the enrollment in CMI, and then analyzed the data generated from the Chinese General Social Survey in 2015,2018 and 2021 respectively. A comparison of factors regarding sociodemographic characteristics, family economic status, social security status, and health status was conducted between individuals enrolled and unenrolled in CMI using Mann-Whitney U test and Chi-square test. Binary logistic regression analysis was used to explore factors influencing the enrollment status of CMI.

RESULTS

Of all individuals, the proportion of enrolled individuals shows an increasing trend year by year, with 8.7%,11.8% and 14.1% enrolled in CMI in 2015,2018 and 2021, respectively. The binary regression analysis further suggested that the factors associated with the enrollment in CMI were consistent in 2015,2018 and 2021.We found that individuals divorced, obese, who had a higher level of education, had non-agricultural household registration, perceived themselves as the upper social status, conducted daily exercise, had more family houses, had a car, had investment activities, or did not have basic health insurance were more likely to be enrolled in CMI.

CONCLUSIONS

We identified multidimensional factors associated with the enrollment of CMI, which help inform the government and insurance industry to improve the coverage of CMI.

Gross total resection and survival outcomes in elderly patients with spinal chordoma: a SEER-based analysis

Objective

The association between aggressive resection and improved survival for adult spinal chordoma patients has not been well characterized in the geriatric population. Thus, the present study aimed to elucidate the relationship between gross total resection (GTR) and survival outcomes for patients across different age groups.

Methods

The authors isolated all adult patients diagnosed with spinal chordoma from the 2000-2019 Surveillance, Epidemiology, and End Results database and divided patients into three surgical subgroups: no surgery, subtotal resection (STR), and GTR. Kaplan-Meier curves with a log-rank test were used to discern differences in overall survival (OS) between surgical subgroups. Univariate and multivariate analyses were used to identify prognostic factors of mortality.

Results

There were 771 eligible patients: 227 (29.4%) received no surgery, 267 (34.6%) received STR, and 277 (35.9%) received GTR. Patients receiving no surgery had the lowest 5-year OS (45.2%), 10-year OS (17.6%), and mean OS (72.1 months). After stratifying patients by age, our multivariate analysis demonstrated that patients receiving GTR aged 40-59 (HR=0.26, CI=0.12-0.55, p<0.001), 60-79 (HR=0.51, CI=0.32-0.82, p=0.005), and 80-99 (HR=0.14, CI=0.05-0.37, p<0.001) had a lower risk of mortality compared to patients undergoing no surgery. The frequency of receiving GTR also decreased as a function of age (16.4% [80-99 years] vs. 43.2% [20-39 years]; p<0.001), but the frequency of receiving radiotherapy was comparable across all age groups (48.3% [80-99 years] vs. 45.5% [20-39 years]; p=0.762).

Conclusion

GTR is associated with improved survival for middle-aged and elderly patients with spinal chordoma. Therefore, patients should not be excluded from aggressive resection on the basis of age alone. Rather, the decision to pursue surgery should be decided on an individual basis.

The effect of insurance status on treatment modality in advanced oral cavity cancer

BACKGROUND

Insurance status has been shown to impact survival outcomes. We sought to determine whether insurance affects the choice of treatment modality among patients with advanced (T4) oral cavity squamous cell carcinoma.

METHODS

This is a retrospective, population-based cohort study using the Survival, Epidemiology, and End Results Program database. The population included all adult (age ≥ 18) patients with advanced (T4a or T4b) oral cavity squamous cell carcinoma diagnosed from 2007 to 2016. The main outcome was the odds of receiving definitive treatment, defined as primary surgical resection. Insurance status was categorized into uninsured, any Medicaid, and insured groups. Univariable, multivariable, and subgroup analyses were performed.

RESULTS

The study population consisted of 2628 patients, of whom 1915 (72.9%) were insured, 561 (21.3%) had Medicaid, and 152 (5.8%) were uninsured. The multivariable model showed that patients who were 80 years or older, unmarried, received treatment in the pre-Affordable Care Act (ACA) period, and who were on Medicaid or uninsured were significantly less likely to receive definitive treatment. Insured patients were significantly more likely to receive definitive treatment compared to those on Medicaid or uninsured (OR = 0.59, 95% CI 0.46-0.77, p < 0.0001 [Medicaid vs. Insured]; and OR = 0.48, 95% CI 0.31-0.73 p = 0.001 [Uninsured vs. Insured]), however these differences did not persist when considering only those patients treated following the 2014 expansion of the ACA.

CONCLUSIONS

Insurance status is significantly associated with treatment modality among adults with advanced stage (T4a) oral cavity squamous cell carcinoma. These findings support the premise of expanding insurance coverage in the US.

Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016

PURPOSE

The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected.

METHODS

The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months.

RESULTS

A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states.

CONCLUSION

Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.

Reducing disparities and achieving health equity in colorectal cancer screening

Increases in colorectal cancer screening are linked to the declining incidence of the disease over the past three decades. These favorable trends, however, are not observed in marginalized racial and ethnic populations with disproportionately lower rates of screening, higher disease incidence, and increased mortality despite advances in health technology and policy. This review describes the differences in screening uptake and test selection amongst racial and ethnic groups, discusses known obstacles and facilitators that impact screening, and highlights existing frameworks developed to achieve health equity in colorectal cancer screening.

Colorectal cancer in young patients below screening age - Demographic and socioeconomic factors associated with incidence and survival

BACKGROUND

While early onset colorectal cancer (EOCRC) has previously been defined as CRC in patients younger than age 50, recent screening guidelines have been lowered to 45. With more younger patients aged 45-50 are now being screened, incidence trend and outcomes of very early EOCRC (20-44) remains unclear.

METHOD

Surveillance, Epidemiology, and End Results database was analyzed between 2006 and 2016 using Joinpoint tool to evaluate annual percentage change (APC) in incident rates, focusing on race/ethnicity and socioeconomic status (SES). Cancer specific survival (CSS) was assessed using univariate and multivariate analysis.

RESULTS

41,815 EOCRC patients met inclusion criteria. Incidence has increased significantly in both age groups (APC in age group 20-44 = 1.21 and 45-49 = 1.06). Increase incidence of very early EOCRC was observed in White and Hispanic racial/ethnic groups (ACP 1.68 and 2.63), as well as population from counties with high poverty, unemployment, language barrier, foreign born resident, and high school dropout rates (ACP 2.07, 1.87, 1.21, 1.28 and 2.02 respectively). Further, the 5-year CSS was worse in Black patients, and patients from counties with high poverty, unemployment and high school dropouts rates (Age group 20-44, 63.11%, 66.39%, 67.48% and 66.95% respectively). On multivariate analysis, living in high poverty counties was an independent risk factor for poorer CSS for very early EOCRC (HR 1.20, 95% CI 1.07-1.34, p = 0.002). Multivariate analysis was adjusted by sex, pathology type, site of disease, disease extension and surgical treatment history.

CONCLUSION

Very early EOCRC incidence increases in White, Hispanic and poor patients, and outcomes are worse for minority and low-income patients. Further study on very early EOCRC is needed among those patients.

Changes in coverage among non-elderly adults with chronic diseases following Affordable Care Act implementation

IMPORTANCE

Changes in insurance coverage after the Affordable Care Act (ACA) among non-elderly adults with self-reported chronic conditions across income categories have not been described.

OBJECTIVE

To examine changes in insurance coverage after the ACA among non-elderly adults with chronic conditions across income categories, by geographic region.

DESIGN

We compared self-reported access to health insurance pre-ACA (2010-2013) and post-ACA (2014-2017) for individuals 18-64 years of age with ≥ 2 chronic conditions, including hypertension, heart disease/stroke, emphysema, diabetes, asthma, cancer, and arthritis, across regions using a logistic regression approach, adjusted for covariates. We also assessed U.S. Census regional differences in insurance coverage post-ACA using modified Poisson regression models with robust variance and calculated the risk ratio (RR) of being uninsured by region, with the Northeast as the reference category. Within each region, we then examined changes in insurance coverage by income level among non-elderly individuals with any chronic condition.

SETTING

2010-2017 household component of the nationally representative Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

All members of surveyed households during five interviews over a two-year period.

INTERVENTION

Start of insurance coverage expansion under the ACA.

MAIN OUTCOMES

Health insurance status.

RESULTS

On average nationwide, non-elderly adults with self-reported chronic conditions experienced increased insurance coverage associated with the ACA (diabetes: +6.41%, high-blood pressure: +6.09%, heart disease: +6.50%, asthma: +6.37%, arthritis: +6.77%, and ≥ 2 chronic conditions: +6.39%). Individuals in the West region reported the largest increases (diabetes +9.71%, high blood pressure +8.10%, and heart disease/stroke +8.83 %, asthma +9.10%, arthritis +8.39%, and ≥ 2 chronic conditions +8.58). In contrast, individuals in the South region reported smaller increases in insurance coverage post-ACA among those with diabetes, heart disease/stroke, and asthma compared to the Midwest and West. The Northeast region, which had the highest levels of insurance coverage pre-ACA, exhibited the smallest increase in reported coverage post-ACA. Reported insurance coverage improved across all regions for adults with any chronic condition across income levels, most notably for very low- and low-income individuals. A further cross-sectional comparison after the ACA demonstrated important residual differences in insurance coverage, despite the gains in all regions. When compared to the Northeast, adults with any self-reported chronic conditions living in the South were more likely to report no insurance coverage (diabetes: RR 1.99, p-value <0.001, high blood pressure: RR 2.02, p-value <0.001, heart diseases/stroke: RR 2.55, p-value <0.001, asthma RR 2.21, p-value <0.001, arthritis: RR 2.25, p-value <0.001), and ≥ 2 chronic condition (RR 2.29, p-value <0.001).

CONCLUSION AND RELEVANCE

The ACA was associated with meaningful increases in insurance coverage for adults with any self-reported chronic condition in all US regions, most notably in the West region and among those with lower incomes, suggesting a nation-wide trend to improved access to health insurance following implementation. However, intra-regional comparisons after ACA implementation showed important differences. Individuals with ≥2 chronic conditions in the South were 2.29 times less likely to have insurance coverage in comparison to their peers in the Northeast. Though the post-ACA improvements in reported access to health insurance coverage affected all US regions, the reported experience of those with multiple chronic conditions in the South point to continued barriers for those most likely to benefit from access to health insurance coverage. Medicaid expansion in the South would likely result in increased insurance coverage for individuals with chronic conditions and improve health care outcomes.

Medicaid expansion is associated with a higher likelihood of early diagnosis, resection, transplantation, and overall survival in patients with hepatocellular carcinoma

BACKGROUND

We examined the association between Medicaid expansion (ME) and the diagnosis, treatment, and survival of patients with hepatocellular carcinoma (HCC).

METHODS

We identified patients with HCC <65yrs with Medicaid or without insurance within the National Cancer Database before (2010-2013) or after (2015-2017) ME with early (cT1) or intermediate/advanced (cT2-T4 or M1) disease.

RESULTS

We identified 4848 patients with HCC before and 4526 after ME. Prior to ME, there was no association between future ME status and diagnosis of early HCC (34.5% vs. 32.9%). There was no association between future ME status and treating early HCC with ablation, resection, or transplantation. Patients with early HCC in future ME states were less likely to die (HR = 0.81, 95% CI: 0.67-0.98). After ME, patients in ME states were more likely to be diagnosed with early HCC (39.2% vs. 32.1%). Patients with early disease in ME states were more likely to undergo resection (OR=1.78, 95% CI: 1.16-2.75) or transplantation (OR=3.20, 95% CI: 1.40-7.33). There was a further associated decrease in the hazard of death (HR=0.68, 95% CI: 0.54-0.86).

CONCLUSION

ME was associated with early diagnosis of HCC. For early HCC, ME was associated with increased utilization of resection and transplantation and improvement in survival.

What Does the State Innovation Model Experiment Tell Us About States' Capacity to Implement Complex Health Reforms?

Policy Points To make progress implementing payment and delivery system reforms, state governments need to make genuine stakeholder engagement routine business, develop reforms that build on past successes, and ensure health reform is a top priority for bureaucrats and political leaders. To support state-led reform initiatives, the federal government needs to provide financial support directly to state governments; build bureaucratic capability in supporting state officials with policy design and implementation; develop more flexible, outcome-focused funding programs; reform its own programs, particularly Medicare; and commit to a long-term strategy for progressing payment and delivery system reforms.

CONTEXT

For decades, Americans have debated whether the states need federal government support to reform health care. The Affordable Care Act has allowed the federal government to trial innovative ways of accelerating state-led reform initiatives through the State Innovation Model (SIM), which was run by the Centers for Medicare and Medicaid Services Innovation Center between 2013 and 2019. This study assesses states' progress implementing health reforms under SIM and examines how well the federal government supported them.

METHODS

Detailed case studies were conducted in six states: Arkansas, Connecticut, Oregon, New York, Tennessee, and Washington. Data was collected from SIM evaluation and annual reports and through semistructured interviews with 39 expert informants, mostly state or federal officials involved in SIM. Preliminary findings were tested and refined through an online forum with health policy experts, facilitated by the Milbank Memorial Fund.

FINDINGS

States that made the most progress implementing reforms had a strong track record and managed to sustain stakeholder, bureaucratic, and political support for their reform agenda. There was a clear correlation between past reform success and success under SIM, which raises questions about the value of federal government support beyond providing funding. State officials said the federal government could better support states, particularly those with less reform experience, by providing tailored advice that helped state officials overcome problems designing and implementing reforms. State officials also said the federal government could better support them by reforming their own programs, particularly Medicare, and committing to a long-term strategy for health system reform.

CONCLUSIONS

States can make some progress reforming health care on their own, but real progress requires long-term cooperation between state and federal governments. Federal initiatives like SIM that foster cooperation between governments should be continued but refined so they provide better support to states.

Contemporary Assessment of the Economic Burden of Upper Urinary Tract Stone Disease in the United States: Analysis of 1-year Healthcare Costs, 2011-2018

Background The United States healthcare landscape has witnessed numerous changes since implementation of the Affordable Care Act coupled with rising prevalence of upper urinary tract stone disease. Data on the economic burden of stone disease during this period are lacking, providing the objective of our study. Materials and Methods Adults diagnosed with stone disease from 2011-2018 were identified from PearlDiver Mariner, a national all-payer database reporting reimbursements and prescription costs for all healthcare encounters. Patients undergoing operative and non-operative care were identified. Time trends in annual expenditures were evaluated. Multivariable analysis evaluated determinants of spending. Results A total of $10B were spent on stone disease management between 2011-2018 (median overall annual expenditure=$1.4B) among 786,756 patients. Inpatient, prescription and outpatient costs accounted for 34.7%, 20.7% and 44.6% of expenditures respectively. 78% of patients were managed non-operatively (total cost=$6.9B). Average overall cost per encounter was $13,587 ($17,102 for surgical vs. $11,174 for non-surgical care). Expenditures on inpatient care decreased significantly over time, while expenditures on prescriptions and outpatient care increased significantly. On multivariable analysis, higher Charlson Comorbidity Index was associated with higher spending, while associations for age, insurance and region varied by treatment modality. Conclusions The economic burden of stone disease management is substantial, dominated by expenditure on non-operative management and outpatient care. Expenditures for prescription and outpatient care are rising, with the only consistent predictor of higher spending being Charlson Comorbidity Index. Spending variation according to demographic, clinical, and geographic factors was evident.

Analysis of core processes of the MRI workflow for improved capacity utilization

PURPOSE

To analyze core processes of the MRI workflow and to evaluate efficiency for improved patient throughput and capacity utilization.

METHOD

Prospective data collection was conducted during a four-week time period and a total sum of 160 working hours for each of the two 1.5 T MRI scanners. Three core processes defined the value stream of patient handling before, during and after the MRI examination: i) Scheduling & Registration, ii) Organization & Preparation, and iii) MR scan. Quantitative data was collected for six essential time intervals of the MRI workflow.

RESULTS

A total of 302 MRI examinations were assessed. The workflow analysis revealed that effective utilization of scan capacity during operating hours varied by scanner (Scanner 1: 77 % / Scanner 2: 85 %). Mean process times for were: patient preparation time 18.9 min (±15.1) p = 0.11, scan preparation time 5.7 min (±4.0) p = 0,015, effective scan time 39.6 min (±18.0) p < 0.0001, scan room occupation time 50.9 min (±21.0) p < 0.0001, clean-up time 5.6 min (±3.2) p = 0.001, total patient handling time 69.7 min (±26.3) p < 0.0001, turnover time 13.4 min (±21.4) p = 0.65.

CONCLUSIONS

This study demonstrates the utility and applicability of a standardized core processes analyses for MRI scanning, which identified underutilization of scanning capacities, related to multiple factors, such as punctuality of patients, the number of same day cancellations, the process of placing an IV access and patient transport contribute to underutilization of MRI scanners. Furthermore, proactive patient management and effective communication with patients and referring physicians might have relevant time saving potential in the scan room.

Has the Affordable Care Act Been Associated with Increased Insurance Coverage and Early-stage Diagnoses of Bone and Soft-tissue Sarcomas in Adults?

BACKGROUND

Treatment of bone and soft-tissue sarcomas can be costly, and therefore, it is not surprising that insurance status of patients is a prognostic factor in determining overall survival. Furthermore, uninsured individuals with suspected bone and/or soft-tissue masses routinely encounter difficulty in obtaining access to basic healthcare (such as office visits, radiology scans), and therefore are more likely to be diagnosed with later stages at presentation. The Patient Protection and Affordable Care Act (ACA) mandate of 2010 aimed to increase access to care for uninsured individuals by launching initiatives, such as expanding Medicaid eligibility, subsidizing private insurance, and developing statewide mandates requiring individuals to have a prescribed minimum level of health insurance. Although prior reports have demonstrated that the ACA increased both coverage and the proportion of early-stage diagnoses among patients with common cancers (including breast, colon, prostate, and lung), it is unknown whether similar improvements have occurred for patients with bone and soft-tissue sarcomas. Understanding changes in insurance coverages and stage at diagnosis of patients with bone and soft-tissue sarcomas would be paramount in establishing policies that will ensure orthopaedic cancer care is made equitable and accessible to all.

QUESTIONS/PURPOSES

(1) Has the introduction of the ACA been associated with changes in insurance coverage for adult patients with newly diagnosed bone and soft-tissue sarcomas? (2) Did the introduction of health reforms under the ACA lead to an increased proportion of sarcoma diagnoses occurring at earlier disease stages?

METHODS

The 2007 to 2015 Surveillance, Epidemiology and End Results database was queried using International Classification of Diseases for Oncology codes for primary malignant bone tumors of the upper and lower extremity (C40.0 to C40.3), unspecified or other overlapping bone, articular cartilage, and joint and/or ribs, sternum, or clavicle (C40.8 to C40.9, C41.3, and C41.8 to C41.9), vertebral column (C41.2), pelvis (C41.4, C41.8, and C41.9), and soft-tissue sarcomas of the upper or lower extremity and/or pelvis (C49.1, C49.2, and C49.5). A total of 15,287 patients with newly diagnosed cancers were included, of which 3647 (24%) were malignant bone tumors and 11,640 (76%) were soft-tissue sarcomas. The study sample was divided into three cohorts according to specified time periods: pre-ACA from 2007 to 2010 (6537 patients), pre-Medicaid expansion from 2011 to 2013 (5076 patients), and post-Medicaid expansion from 2014 to 2015 (3674 patients). The Pearson chi square tests were used to assess for changes in the proportion of Medicaid and uninsured patients across the specified time periods: pre-ACA, pre-expansion and post-expansion. A differences-in-differences analysis was also performed to assess changes in insurance coverage for Medicaid and uninsured patients among states that chose to expand Medicaid coverage in 2014 under the ACA's provision versus those who opted out of Medicaid expansion. Since the database switched to using the American Joint Commission on Cancer (AJCC) 7th edition staging system in 2010, linear regression using data only from 2010 to 2015 was performed that assessed changes in cancer stage at diagnosis from 2010 to 2015 alone. After stratifying by cancer type (bone or soft-tissue sarcoma), Pearson chi square tests were used to assess for changes in the proportion of patients who were diagnosed with early, late, and unknown stage at presentation before Medicaid expansion (2011-2013) and after Medicaid expansion (2014-2015) among states that chose to expand versus those who did not.

RESULTS

After stratifying by time cohorts: pre-ACA (2007 to 2010), pre-expansion (2011 to 2013) and post-expansion (2014 to 2015), we observed that the most dramatic changes occurred after Medicaid eligibility was expanded (2014 onwards), with Medicaid proportions increasing from 12% (pre-expansion, 2011 to 2013) to 14% (post-expansion, 2014 to 2015) (p < 0.001) and uninsured proportions decreasing from 5% (pre-expansion, 2011 to 2013) to 3% (post-expansion, 2014 to 2015) (p < 0.001). A differences-in-differences analysis that assessed the effect of Medicaid expansion showed that expanded states had an increase in the proportion of Medicaid patients compared with non-expanded states, (3.6% [95% confidence interval 0.4 to 6.8]; p = 0.03) from 2014 onwards. For the entire study sample, the proportion of early-stage diagnoses (I/II) increased from 56% (939 of 1667) in 2010 to 62% (1137 of 1840) in 2015 (p = 0.003). Similarly, the proportion of unknown stage diagnoses decreased from 11% (188 of 1667) in 2010 to 7% (128 of 1840) in 2015 (p = 0.002). There was no change in proportion of late-stage diagnoses (III/IV) from 32% (540 of 1667) in 2010 to 31% (575 of 1840) in 2015 (p = 0.13).

CONCLUSION

Access to cancer care for patients with primary bone or soft-tissue sarcomas improved after the ACA was introduced, as evidenced by a decrease in the proportion of uninsured patients and corresponding increase in Medicaid coverage. Improvements in coverage were most significant among states that adopted the Medicaid expansion of 2014. Furthermore, we observed an increasing proportion of early-stage diagnoses after the ACA was implemented. The findings support the preservation of the ACA to ensure cancer care is equitable and accessible to all vulnerable patient populations.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Affordable Care Act's Missing Consensus: Values, Attitudes, and Experiences Associated with Competing Health Reform Preferences

Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency-and the sitting president-have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs.

Hospital network participation and outcomes following elective posterior lumbar fusions - are mergers effective?

BACKGROUND CONTEXT

Due to financial pressures associated with healthcare reforms, an increasing number of hospitals are now merging (or consolidating) into networks (or systems). However, it remains unclear how these mergers or network participations affect quality of care and/or costs.

PURPOSE

The current study aims to evaluate the impact of hospital network participation on 90-day complications, charges, and costs following elective posterior lumbar fusions (PLFs).

STUDY DESIGN

Retrospective review of a 100% national sample of Medicare claims from 2010 to 2014 (SAF100).

STUDY SAMPLE

All Medicare-eligible patients undergoing elective 1-to-3 level PLFs for degenerative lumbar pathology from 2010 to 2014.

OUTCOME MEASURES

Ninety-day complications, charges, and costs.

METHODS

The 2010 to 2014 100% Medicare Standard Analytical Files (SAF100) was used to identify patients undergoing elective 1- to 3-level PLFs for degenerative lumbar pathology. The Dartmouth Atlas for Healthcare hospital-level data, which uses a combination of American Hospital Association and additional source data, was used to identify hospitals that were part of a network (or system) between 2010 and 2014. The study sample was divided into 2 cohorts (network hospitals and non-network hospitals) for analyses. Multivariate logistic regression models were used to compare differences in 90-day complications between network and non-network hospitals, while controlling for baseline demographics (age, gender, region, year of surgery, median household income, co-morbidity burden) and hospital-level characteristics (case volume, teaching status, urban/rural location, and hospital ownership). Generalized linear regression modeling was used to assess for differences in 90-day charges and costs.

RESULTS

A total of 145,141 patients undergoing surgery in 2,186 hospitals were included in the study, out of which 107,919 (74.4%) underwent surgery in a network hospital (N=1,526). Network hospitals were more prevalent in the South or West regions of the United States. Patients in network hospitals had a median household income less than the 5th quintile. Network hospitals were also more likely to have a higher annual case volume of elective 1- to 3-level PLFs, greater number of beds, be located in an urban location, and have a voluntary/nonprofit or proprietary/profit ownership model. Multivariate analyses showed that even though patients undergoing surgery at network hospitals (vs non-network hospitals) had a slightly increased odds of 90-day cardiac complications (7.9% vs 7.4%, odds ratio [OR] 1.07 [95% confidence interval {CI} 1.02-1.12]; p=.010), thromboembolic complications (2.4% vs 2.2%, OR 1.12 [95% CI 1.01-1.20]; p=.025) and emergency department visits (16.4% vs 16.0%, OR 1.06 [95% CI 1.02-1.09]; p=.002), the differences would not be considered clinically significant. Despite a slight decrease in risk-adjusted 90-day reimbursements (-$272), the risk-adjusted 90-day charges were actually significantly higher (+$9,959; p<.001) at network hospitals.

CONCLUSIONS

Even though hospitals that are part of a network do not appear to have significantly different complication rates following elective PLFs, they do have significantly higher risk-adjusted charges as compared to non-network hospitals. Further research is required to understand market-level changes induced by hospital mergers into networks.

Changes in Noninsurance and Care Unaffordability Among Cancer Survivors Following the Affordable Care Act

BACKGROUND

Little is known about changes in socioeconomic disparities in noninsurance and care unaffordability among nonelderly cancer survivors following the Affordable Care Act (ACA).

METHODS

Cancer survivors aged 18-64 years nationwide were identified from the Behavioral Risk Factor Surveillance System. Trend and difference-in-differences analyses were conducted to examine changes in percent uninsured and percent reporting care unaffordability pre-(2011 to 2013) and post-(2014 to 2017) ACA Medicaid expansion, by sociodemographic factors.

RESULTS

A total of 118 631 cancer survivors were identified from Medicaid expansion (n = 72 124) and nonexpansion (n = 46 507) states. Following the ACA, percent uninsured and percent reporting care unaffordability decreased nationwide. Medicaid expansion was associated with a 1.8 (95% confidence interval [CI] = 0.1 to 3.5) percentage points (ppt) net decrease in noninsurance and a 2.9 (95% CI = 0.7 to 5.1) ppt net decrease in care unaffordability. In stratified analyses by sociodemographic factors, substantial decreases were observed in female survivors, those with low or medium household incomes, the unemployed, and survivors with multiple comorbidities. However, we observed slightly increased percentages in reporting noninsurance (ppt = 1.7; 95% CI = -1.2 to 4.5) and care unaffordability (ppt = 3.1, 95% CI = -0.4 to 6.5) in nonexpansion states between 2016 and 2017, translating to 67 163 and 124 160 survivors, respectively.

CONCLUSION

We observed reductions in disparities by sociodemographic factors in noninsurance and care unaffordability among nonelderly cancer survivors following the ACA, with largest decreases in women, those with low or medium income, multiple comorbid conditions, the unemployed, and those residing in Medicaid expansion states. However, the uptick of 82 750 uninsured survivors in 2017, mainly from nonexpansion states, is concerning. Ongoing monitoring of the effects of the ACA is warranted, especially in evaluating health outcomes.

Primary single-level lumbar microdisectomy/decompression at a free-standing ambulatory surgical center vs a hospital-owned outpatient department-an analysis of 90-day outcomes and costs

BACKGROUND CONTEXT

While free-standing ambulatory surgical centers (ASCs) have been extolled as lower cost settings than hospital outpatient facilities/departments (HOPDs) for performing routine elective spine surgeries, differences in 90-day costs and complications have yet to be compared between the two types of treatment facilities.

PURPOSE

We carried a comprehensive analysis to report the differences on payments to providers and facilities as a reflection of true costs to patients, employers and health plans for patients undergoing primary, single-level lumbar microdiscectomy/decompression at ASC versus HOPD.

STUDY DESIGN

Retrospective review of Medicare advantage and commercially insured enrollees from the Humana dataset from 2007 to 2017Q1.

OUTCOME MEASURES

To understand the differences in 90-day complications, readmissions, emergency department visits and costs for patients undergoing primary, single-level lumbar microdiscectomy/decompressions at an ASC versus HOPD.

METHODS

The Humana 2007 to 2017Q1 was queried using Current Procedural Terminology codes to identify patients undergoing primary, single-level lumbar microdiscectomy/decompressions. Patients undergoing two-level surgery, open laminectomies, fusions, revision discectomies, and/or deformities were excluded. Service Location codes for HOPD (Location Code 22) and free-standing ASC (Location Code 24) were used to determine surgery treatment facilities. Using propensity scoring, we matched two groups who had surgery performed in ASCs or HOPDs based on age, gender, race, region and Elixhauser comorbidity index. Multivariable logistic regression analyses were performed on matched cohorts to assess for differences in 90-day outcomes between facilities, while controlling for age, gender, race, region, plan, and Elixhauser comorbidity index.

RESULTS

A total of 1,077 and 10,475 primary single-level decompressions were performed in ASCs and HOPDs, respectively. Following a matching algorithm with propensity scoring, the two cohorts were comprised of 990 patients each. Observed differences in 90-day complication rates were not statistically or clinically significant (ASC=9.1% vs. HOPD=10.3%; p=.362) nor were readmissions (ASC=4.5% vs. HOPD=5.3%; p=.466). On average, performing surgery in an ASC versus HOPD resulted in significant cost savings of over $2,000/case in Medicare Advantage ($5,814 vs. $7,829) and over $3,500/case ($10,116 vs. $13,623) in commercial beneficiaries.

CONCLUSION

Performing single-level decompression surgeries in an ASC compared with HOPDs was associated with approximately $2,000 to $3,500 cost-savings per case with no statistically significant impact on complication or readmission rates.

Insurance Loss in the Era of the Affordable Care Act: Association With Access to Health Services

BACKGROUND

Every year, millions of Americans lose their health insurance and remain uninsured for various reasons, potentially impacting access to medical services.

OBJECTIVE

To examine trends in health insurance loss in the periods shortly before and after implementation of Patient Protection and Affordable Care Act (ACA) and to assess the association of past-year health insurance loss with access to health services and medications.

RESEARCH DESIGN AND SUBJECTS

Trends in health insurance loss were examined in 176,961 nonelderly adult participants of the National Health Interview Survey 2011-2017-a representative cross-sectional annual survey of US general population. Multivariable logistic regression models were used to examine access to health services and medications.

MEASURES

Loss of private insurance or Medicaid in the past year; use of emergency room services and hospitalizations; contact with medical providers; affording medical care or medications; cost-related medication nonadherence.

RESULTS

Private health insurance loss decreased from 3.9%-4.0% in 2011-2013 to 2.7% to 3.1% in 2014-2017 (P<0.001); Medicaid loss decreased from 8.5%-8.9% to 4.6%-6.4% in this period (P<0.001). Nevertheless, as late as 2017, ∼6 million uninsured adults reported having lost private insurance or Medicaid in the past year. Loss of either type of health insurance was associated with lower odds of accessing medical providers, but higher odds of not affording medical care and poor adherence to medication regimens to save costs.

CONCLUSIONS

Implementation of ACA was associated with lower risk of health insurance loss. Nevertheless, health insurance loss remains a major barrier to accessing health services and prescribed medications.