1
|
Lee J. Effects of private health insurance on healthcare services during the MERS Pandemic: Evidence from Korea. Heliyon 2023; 9:e22241. [PMID: 38046131 PMCID: PMC10686881 DOI: 10.1016/j.heliyon.2023.e22241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023] Open
Abstract
This study investigates how private health insurance impacted healthcare services during the MERS pandemic in Korea. Using the Korea Health Panel Study (KHPS), this study examines the difference in healthcare utilization between insured and uninsured individuals during the pandemic. If insured individuals use fewer healthcare services than the uninsured during the MERS pandemic, it could be evidence of moral hazard. During the MERS outbreak, the probability of outpatient medical services utilization was lower by 19 % than during non-pandemic periods. All individuals decreased the number of outpatient visits by 7 %. Insured individuals reduced outpatient visits more than the uninsured in response to the MERS pandemic. The increased outpatient utilization by private health insurance could be attributed to both moral hazard and adverse selection. However, given that people with poor health cannot enroll in private health insurance due to the insurance company's screening process, moral hazard leads to increase healthcare utilization rather than adverse selection.
Collapse
Affiliation(s)
- Jugntaek Lee
- Department of Economics, Dongguk University, Seoul, Republic of Korea
| |
Collapse
|
2
|
Benitez JA, Huang H, Johnson PL. The Relationship Between Coronavirus Disease 2019 (COVID-19) Pandemic-linked Job Losses and Health Care Access and Household Financial Health in Medicaid Expansion and Nonexpansion States. Med Care 2023; 61:872-881. [PMID: 37801548 DOI: 10.1097/mlr.0000000000001933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
BACKGROUND Unemployment associated with the coronavirus disease 2019 (COVID-19) pandemic was linked to financial insecurity and disruptions in access to health care. OBJECTIVE To explore whether expanded access to Medicaid mitigated the likelihood of health and non-health financial hardship associated with pandemic-linked job loss. DESIGN We estimate linear regression models comparing differences in the levels of outcomes attributable to pandemic-linked joblessness in Medicaid expansion and nonexpansion states. OBSERVATIONS A total of 20,281 adults aged 19-64 were in the 2021 National Financial Capability Study. MEASURES Our key exposure was job loss, layoffs, and furloughs, attributable to the COVID-19 pandemic. Outcomes under evaluation include indicators of health care access and household financial health. RESULTS Relative to persons reporting pandemic-linked unemployment in nonexpansion states, adults experiencing pandemic-linked job loss in expansion states were less likely to report as uninsured [-6.2 percentage points (PPs); 95% CI: -10.8, -1.6; P < 0.01], having unpaid medical bills (-4.3 PP; 95% CI: -8, -0.6; P < 0.05), having unmet medical needs due to cost (-5.3 PP; 95% CI: -10.1, -0.5; P < 0.05), and having calls from debt collection agencies (-6.9 PP; 95% CI: -10.6, -3.1; P < 0.01). Patterns consistent with Medicaid acting as a safety net for the adverse financial effects of job loss were more pronounced for middle-income households. CONCLUSIONS In economic downturns, such as the COVID-19 crisis, Medicaid can help insulate households from diminished health care access and financial distress associated with job loss.
Collapse
Affiliation(s)
- Joseph A Benitez
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY
| | - Huang Huang
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY
| | - Portia L Johnson
- Department of Consumer Sciences, College of Human Sciences, Alabama Cooperative Extension System, Auburn University, Auburn, AL
| |
Collapse
|
3
|
Qian Z, Chen X, Pucheril D, Al Khatib K, Lucas M, Nguyen DD, McNabb-Baltar J, Lipsitz SR, Melnitchouk N, Cole AP, Trinh QD. Long-Term Impact of Medicaid Expansion on Colorectal Cancer Screening in Its Targeted Population. Dig Dis Sci 2023; 68:1780-1790. [PMID: 36600118 PMCID: PMC9812352 DOI: 10.1007/s10620-022-07797-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion. AIMS To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark. METHODS Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses. RESULTS Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups. CONCLUSIONS Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence.
Collapse
Affiliation(s)
- Zhiyu Qian
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Xi Chen
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Daniel Pucheril
- Department of Surgery, Booshoft School of Medicine, Wright State University, Dayton, OH USA
| | - Khalid Al Khatib
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mayra Lucas
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - David-Dan Nguyen
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Stuart R. Lipsitz
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Nelya Melnitchouk
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Division of General and Gastrointestinal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Alexander P. Cole
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| |
Collapse
|
4
|
Rakus A, Soni A. Association between state Medicaid expansion status and health outcomes during the COVID-19 pandemic. Health Serv Res 2022; 57:1332-1341. [PMID: 36082396 PMCID: PMC9538092 DOI: 10.1111/1475-6773.14044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess post-COVID-19 changes in insurance coverage, health behaviors, and self-assessed health among low-income, non-elderly adults by state Medicaid expansion status. DATA SOURCES We used nationally representative survey data from the 2016 through 2020 Behavioral Risk Factor Surveillance System (BRFSS). The sample was restricted to adults aged 19-64 with household income below 138 percent of the federal poverty level (N = 179,135). STUDY DESIGN We examined a broad set of outcomes related to coverage, health behaviors, and self-assessed health available in the BRFSS. We used a difference-in-differences model to compare changes in outcomes for individuals living in the 35 states and DC that expanded Medicaid under the Affordable Care Act to those in the 15 non-expansion states before and after the COVID-19 pandemic commenced in March 2020. DATA COLLECTION/EXTRACTION METHODS N/A. PRINCIPAL FINDINGS We found that the expansions provided some protection for low-income people during the pandemic. In 2020, relative to earlier years, people in expansion states were more likely to report very good or excellent health (4.9 percentage points, 95%CI = 0.022, 0.076; p < 0.01) and physical health (-0.393 days of poor physical health in the past month, 95%CI = -0.714, -0.072; p < 0.05), lower rates of smoking (-1.9 percentage points, 95%CI = -0.041, 0.004; p < 0.10) and heavy drinking (-1.4 percentage points, 95%CI = -0.025, -0.004; p < 0.01), and higher flu vaccination rates (2.8 percentage points, 95%CI = 0.005, 0.051; p < 0.05) than those in non-expansion states. These benefits were particularly salient for Black and Hispanic individuals. We found no significant differences in insurance coverage, exercise, obesity, and self-assessed mental health between expansion and non-expansion states for the overall low-income sample. However, the expansion was associated with greater insurance coverage for Hispanic adults during the pandemic. CONCLUSIONS Investments in public health through expanding Medicaid may shield low-income populations from some of the health ramifications of public health emergencies.
Collapse
Affiliation(s)
- Alexandra Rakus
- School of Public AffairsAmerican UniversityNW WashingtonDistrict of ColumbiaUSA
| | - Aparna Soni
- School of Public AffairsAmerican UniversityNW WashingtonDistrict of ColumbiaUSA
| |
Collapse
|
5
|
Shadowen H, Alexander M, Guerra L, Zhao X, Palazzolo J, Walker L, Cunningham PJ, Barnes AJ. Virginia Medicaid Expansion: New Members Report Reduced Financial Concerns During The COVID-19 Pandemic. Health Aff (Millwood) 2022; 41:1078-1087. [PMID: 35858118 DOI: 10.1377/hlthaff.2021.01910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid is a critical antipoverty program. Since the Affordable Care Act expanded Medicaid eligibility, millions of newly eligible people have enrolled, creating positive financial improvements for low-income families. We examined the association of Virginia's 2019 Medicaid expansion and changes in health care-related and non-health-care-related financial needs among newly eligible Medicaid enrollees. Our unique survey collected responses between December 2018 and April 2019 from newly enrolled members reporting on experiences in the year before enrollment and between July 2020 and May 2021 from members reporting on experiences one year after enrollment. The follow-up period coincided with the COVID-19 pandemic. Medicaid enrollment was associated with decreases in concern about all financial needs assessed: housing, food, monthly bills, credit card and loan payments, and health care costs. These reductions were broadly similar across demographic subgroups and across the months of the pandemic that overlapped with the follow-up period. We add to the evidence that Medicaid expansion is a social safety-net policy that could improve equity among low-income families, potentially encouraging states that have yet to expand to do so.
Collapse
Affiliation(s)
- Hannah Shadowen
- Hannah Shadowen , Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Xue Zhao
- Xue Zhao, Virginia Commonwealth University
| | - Jennifer Palazzolo
- Jennifer Palazzolo, Virginia Department of Medical Assistance Services, Richmond, Virginia
| | - Lauryn Walker
- Lauryn Walker, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | | | | |
Collapse
|
6
|
McGinty EE, Nair R, Assini-Meytin LC, Stuart EA, Letourneau EJ. Impact of Medicaid Expansion on Reported Incidents of Child Neglect and Physical Abuse. Am J Prev Med 2022; 62:e11-e20. [PMID: 34561125 DOI: 10.1016/j.amepre.2021.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/04/2021] [Accepted: 06/08/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The U.S. Affordable Care Act Medicaid expansion, which allowed states to expand Medicaid coverage to low-income adults beginning in 2014, has reduced the risk factors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental illness. This study examines the associations between Medicaid expansion and the rates of overall, first-time, and repeat reports of child neglect and physical abuse incidents per 100,000 children aged 0-5, 6-12, and 13-17 years. METHODS The 2008-2018 National Child Abuse and Neglect Data System was analyzed using an extension of the difference-in-differences approach that accounts for staggered policy implementation across time. Owing to evidence of nonparallel preperiod trends in the 6 states that expanded Medicaid from 2015 to 2017, the main analyses included 20 states that newly expanded Medicaid in 2014 and 18 states that did not expand Medicaid from 2008 to 2018. Analyses were conducted in 2020-2021. RESULTS Medicaid expansion states were associated with reductions of 13.4% (95% CI= -24.2, -9.6), 14.8% (95% CI= -26.4, -1.4), and 16.0% (-27.6, -2.6) in the average rate of child neglect reports per 100,000 children aged 0-5, 6-12, and 13-17 years, per state-year, relative to control states. Expansion was associated with a 17.3% (95% CI= -28.9, -3.8) reduction in the rate of first-time neglect reports among children aged 0-5 years and with 16.6% (95% CI= -29.3, -1.6) and 18.7% (95% CI= -32.5, -2.1) reductions in the rates of repeat neglect reports among children aged 6-12 and 13-17 years, respectively. There were no statistically significant associations between Medicaid expansion and the rates of physical abuse among children in any age group. CONCLUSIONS Insurance expansions for low-income adults may reduce child neglect.
Collapse
Affiliation(s)
- Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
| | - Reshmi Nair
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Luciana C Assini-Meytin
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth J Letourneau
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
7
|
Abstract
Objectives. To identify the association between Medicaid eligibility expansion and medical debt. Methods. We used difference-in-differences design to compare changes in medical debt for those gaining coverage through Louisiana's Medicaid expansion with those in nonexpansion states. We matched individuals gaining Medicaid coverage because of Louisiana's Medicaid expansion (n = 196 556) to credit report data on medical debt and compared them with randomly selected credit reports of those living in Southern nonexpansion state zip codes with high rates of uninsurance (n = 973 674). The study spanned July 2014 through July 2019. Results. One year after Louisiana Medicaid expansion, medical collections briefly rose before declining by 8.1 percentage points (95% confidence interval [CI] = -0.107, -0.055; P ≤ .001), or 13.5%, by the third postexpansion year. Balances also briefly rose before falling by 0.621 log points (95% CI = -0.817, -0.426; P ≤ .001), or 46.3%. Conclusions. Louisiana's Medicaid expansion was associated with a reduction in the medical debt load for those gaining coverage. These results suggest that future Medicaid eligibility expansions may be associated with similar improvements in the financial well-being of enrollees.
Collapse
Affiliation(s)
- Kevin Callison
- Kevin Callison and Brigham Walker are with the Department of Health Policy and Management, Tulane School of Public Health and Tropical Medicine, New Orleans, LA. Brigham Walker is also with ConcertAI, Boston, MA
| | - Brigham Walker
- Kevin Callison and Brigham Walker are with the Department of Health Policy and Management, Tulane School of Public Health and Tropical Medicine, New Orleans, LA. Brigham Walker is also with ConcertAI, Boston, MA
| |
Collapse
|
8
|
Thorsness R, Swaminathan S, Lee Y, Sommers BD, Mehrotra R, Nguyen KH, Kim D, Rivera-Hernandez M, Trivedi AN. Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults. J Am Soc Nephrol 2021; 32:1425-1435. [PMID: 33795426 PMCID: PMC8259656 DOI: 10.1681/asn.2020101511] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/30/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care. METHODS Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion). RESULTS The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period. CONCLUSIONS The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.
Collapse
Affiliation(s)
- Rebecca Thorsness
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Shailender Swaminathan
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island,Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Kevin H. Nguyen
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Daeho Kim
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amal N. Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island,Providence Veterans Affairs Medical Center, Providence, Rhode Island
| |
Collapse
|
9
|
Abstract
The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All.
Collapse
Affiliation(s)
- Benjamin D Sommers
- Benjamin D. Sommers ( bsommers@hsph. harvard. edu ) is a professor of health policy and economics in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an associate professor of medicine at Brigham and Women's Hospital, both in Boston, Massachusetts
| |
Collapse
|
10
|
Abstract
Income inequality estimates based on traditional poverty measures do not capture the effects of health care spending and health insurance. To explore the distributional effects of the Affordable Care Act's (ACA's) expansion of health benefits and the resulting income inequality, this study used alternative income measures that incorporate the value of the ACA's health insurance changes under the law. The study simulated the impact of the ACA on income inequality in 2019 compared with a scenario without the ACA. We found that the ACA reduced income inequality and that the decrease was much larger in states that expanded Medicaid than in states that did not. We also decomposed the effect of the ACA on inequality by race/ethnicity, age, and family educational attainment. The ACA reduced inequality both across groups and within these groups. With efforts to repeal the ACA-specifically, California v. Texas-having shifted from Congress to the courts, it remains important to consider the consequences of fully repealing the ACA, which would likely reverse reduced inequality observed under the law.
Collapse
Affiliation(s)
- Matthew Buettgens
- Matthew Buettgens is a senior fellow in the Health Policy Center at the Urban Institute, in Washington, D.C
| | - Fredric Blavin
- Fredric Blavin is a principal research associate in the Health Policy Center at the Urban Institute
| | - Clare Pan
- Clare Pan is a research associate in the Health Policy Center at the Urban Institute
| |
Collapse
|
11
|
Acharya Y, Hillemeier MM, Sznajder KK, Kjerulff KH. Out-of-Pocket Medical Bills from First Childbirth and Subsequent Childbearing. Womens Health Issues 2021; 31:17-23. [PMID: 32896469 PMCID: PMC7770019 DOI: 10.1016/j.whi.2020.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Many families in the United States struggle to pay medical debt. This study aims to investigate the association between having out-of-pocket medical bills from first childbirth sent to debt collection agencies and subsequent childbearing. METHODS As part of a large-scale birth cohort study (N = 2,169), women in Pennsylvania who delivered their first child in 2009 through 2011 were asked if any of the out-of-pocket medical expenditures resulting from the delivery were sent to debt collection agencies. Logistic regression models were used to assess the association between childbirth medical bills going to debt collections in the first year after delivery and subsequent childbearing over the following 2 years, controlling for relevant confounders, including maternal age, education, race/ethnicity, marital status, poverty level, insurance coverage, pregnancy intendedness, difficulty paying for basic needs, plans to have another child, pregnancy complications, and childbirth maternal and neonatal complications. RESULTS Women received out-of-pocket medical bills for as much as $32,000. Overall, 8.3% reported having medical bills from the childbirth sent to debt collections. These women were substantially less likely to have a subsequent child during the follow-up period (22.4%) compared with their counterparts, whose medical bills did not go to collections (44.4%; adjusted odds ratio, 0.60; 95% confidence interval, 0.39-0.93). CONCLUSIONS When out-of-pocket medical bills from first childbirth are more than American families can afford to pay, they may postpone having a second child. This finding may be particularly true when childbirth medical bills are sent to debt collection agencies.
Collapse
Affiliation(s)
- Yubraj Acharya
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania.
| | - Marianne M Hillemeier
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania
| | - Kristin K Sznajder
- Department of Public Health Sciences, The Pennsylvania State University, Hershey, Pennsylvania
| | - Kristen H Kjerulff
- Departments of Public Health Sciences and Obstetrics and Gynecology, The Pennsylvania State University, Hershey, Pennsylvania
| |
Collapse
|
12
|
Abstract
Purpose: To examine indebtedness for medical care among racial and ethnic minorities and people with serious psychological distress (SPD) using a nationally representative sample in the United States. Methods: Using the 2014–2017 Medical Expenditure Panel Survey, we examine medical debt among individuals with SPD. We develop a logistic regression model to estimate the odds of medical debt by SPD status. We stratify the odds of medical debt for those with SPD by insurance type. Results: The results indicate that after controlling for predisposing, enabling, and physical needs factors, those experiencing SPD have double the odds of having medical debt compared with those without SPD. Non-Hispanic blacks had higher odds of medical debt compared with non-Hispanic whites. We find that individuals with SPD covered under private health insurance have double the odds of having medical debts; and those who are uninsured have triple the odds of having medical debt compared with their counterparts without SPD. Conclusion: The findings suggest that odds of medical debt are higher among people with SPD, even when insured. Additional health policy initiatives to address medical debt among those with SPD may be warranted.
Collapse
Affiliation(s)
- Priscilla J Novak
- Department of Health Policy and Management, School of Public Health, University of Maryland at College Park, College Park, Maryland, USA
| | - Mir M Ali
- Department of Health Policy and Management, School of Public Health, University of Maryland at College Park, College Park, Maryland, USA
| | - Maria X Sanmartin
- Department of Health Professions, Hofstra University, Hempstead, New York, USA
| |
Collapse
|
13
|
Abstract
The Affordable Care Act (ACA) was enacted in 2010 to address both high uninsured rates and rising health care spending through insurance expansion reforms and efforts to reduce waste. It was expected to have a variety of impacts in areas within the purview of economics, including effects on health care coverage, access to care, financial security, labor market decisions, health, and health care spending. To varying degrees, legislative, executive, and judicial actions have altered its implementation, affecting the extent to which expectations in each of these dimensions have been realized. We review the ACA's reforms, the subsequent actions that countered them, and the expected and realized effects on coverage, access to care, financial security, health, labor market decisions, and health care spending.
Collapse
|
14
|
Gangopadhyaya A, Blavin F, Braga B, Gates J. Credit where it is due: Investigating pathways from earned income tax credit expansion to maternal mental health. Health Econ 2020; 29:975-991. [PMID: 32597518 DOI: 10.1002/hec.4034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 06/11/2023]
Abstract
While earned income tax credit (EITC) expansions are typically associated with improvements in maternal mental health, little is known about the mechanisms through which the program affects this outcome. The EITC could primarily affect mental health through changes in family financial resources, changes in labor supply or changes in health insurance coverage of participants. We attempt to disentangle these mechanisms by assessing the effects of state and federal EITC expansion on mental health, employment, and health insurance by maternal marital status. We find that federal EITC expansions are associated with improved self-reported mental health for all mothers and large positive effects on employment for unmarried mothers. State EITC expansions are associated with improvements in mental health for married mothers only and have no effect on employment for married or unmarried mothers. Overall and for most subgroups of mothers, we find little association between EITC expansions and changes in health insurance coverage. These findings suggest that while EITC expansions improved mental health for unmarried mothers through a combination of the credit and employment effects, for married mothers, improved mental health is driven through the direct credit alone.
Collapse
Affiliation(s)
- Anuj Gangopadhyaya
- Health Policy Center, Urban Institute, Washington, District of Columbia, USA
| | - Fredric Blavin
- Health Policy Center, Urban Institute, Washington, District of Columbia, USA
| | - Breno Braga
- Center on Labor, Human Services, and Population, Urban Institute, Washington, District of Columbia, USA
| | - Jason Gates
- Tepper School of Business, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
15
|
Scott JW, Shrime MG, Stewart BT, Arbabi S, Bulger EM, Cuschieri J, Maier RV, Robinson BR. Authors’ reply: Understanding state-level Medicaid expansion in the context of nationwide data. J Trauma Acute Care Surg 2020; 89:e20-e21. [DOI: 10.1097/ta.0000000000002733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
McMorrow S, Blumberg LJ, Holahan J. Ten Years Later: Reflections on Critics' Worst-Case Scenarios for the Affordable Care Act. J Health Polit Policy Law 2020; 45:465-483. [PMID: 32186341 DOI: 10.1215/03616878-8255421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The primary goals of the Affordable Care Act (ACA) were to increase the availability and affordability of health insurance coverage and thereby improve access to needed health care services. Numerous studies have overwhelmingly confirmed that the law has reduced uninsurance and improved affordability of coverage and care for millions of Americans. Not everyone believed that the ACA would lead to positive outcomes, however. Critics raised numerous concerns in the years leading up to the law's passage and full implementation, including about its consequences for national health spending, labor supply, employer health insurance markets, provider capacity, and overall population health. This article considers five frequently heard worst-case scenarios related to the ACA and provides research evidence that these fears did not come to pass.
Collapse
|
17
|
McInerney M, Winecoff R, Ayyagari P, Simon K, Bundorf MK. ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study. Inquiry 2020; 57:46958020935229. [PMID: 32720837 PMCID: PMC7388087 DOI: 10.1177/0046958020935229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.
Collapse
|
18
|
Johnston EM, McMorrow S, Thomas TW, Kenney GM. ACA Medicaid Expansion and Insurance Coverage Among New Mothers Living in Poverty. Pediatrics 2020; 145:peds.2019-3178. [PMID: 32295817 DOI: 10.1542/peds.2019-3178] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act's (ACA's) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty. METHODS We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010-2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers. RESULTS A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers. CONCLUSIONS ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.
Collapse
|
19
|
Barnes JM, Johnson KJ, Adjei Boakye E, Sethi RKV, Varvares MA, Osazuwa‐Peters N. Impact of the Patient Protection and Affordable Care Act on cost‐related medication underuse in nonelderly adult cancer survivors. Cancer 2020; 126:2892-2899. [DOI: 10.1002/cncr.32836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | - Kimberly J. Johnson
- Brown School Washington University in St. Louis St. Louis Missouri
- Siteman Cancer Center Washington University in St. Louis St. Louis Missouri
| | - Eric Adjei Boakye
- Department of Population Science and Policy Southern Illinois University School of Medicine Springfield Illinois
- Simmons Cancer Institute at Southern Illinois University Southern Illinois University School of Medicine Springfield Illinois
| | - Rosh K. V. Sethi
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary Harvard Medical School Boston Massachusetts
| | - Mark A. Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary Harvard Medical School Boston Massachusetts
| | - Nosayaba Osazuwa‐Peters
- Department of Otolaryngology–Head and Neck Surgery Saint Louis University School of Medicine St. Louis Missouri
- Saint Louis University Cancer Center St. Louis Missouri
| |
Collapse
|
20
|
Gotanda H, Jha AK, Kominski GF, Tsugawa Y. Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study. BMJ 2020; 368:m40. [PMID: 32024637 PMCID: PMC7190017 DOI: 10.1136/bmj.m40] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING United States. PARTICIPANTS A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS 37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. CONCLUSION Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.
Collapse
Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UCLA Center for Health Policy Research, Los Angeles, CA, USA
| | - Yusuke Tsugawa
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UCLA Center for Health Policy Research, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
21
|
Abstract
Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (-1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits-even for those with established access to safety-net care.
Collapse
Affiliation(s)
- John A Graves
- John A. Graves ( john. graves@vanderbilt. edu ) is an associate professor in the Department of Health Policy, Vanderbilt University School of Medicine, in Nashville, Tennessee
| | - Laura A Hatfield
- Laura A. Hatfield is an associate professor in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - William Blot
- William Blot is a professor of medicine in the Vanderbilt University School of Medicine
| | - Nancy L Keating
- Nancy L. Keating is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital, both in Boston
| | - J Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School
| |
Collapse
|
22
|
Kino S, Sato K, Kawachi I. Spillover benefit of improved access to healthcare on reducing worry about housing and meal affordability. Int J Equity Health 2018; 17:174. [PMID: 30466443 PMCID: PMC6251117 DOI: 10.1186/s12939-018-0877-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/21/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The Affordable Care Act Medicaid expansion improved access to health insurance among low-income populations. We sought to examine the spillover benefits of the ACA Medicaid expansion on ability to afford rent/mortgage and purchase of nutritious meals. METHODS Using data from the Behavioral Risk Factor Surveillance System (BRFSS) we analyzed individuals aged 18-64 years residing in 12 U.S. states (including five ACA Medicaid expansion states) in 2015. Our treatment of interest was access to health insurance, instrumented by the ACA Medicaid expansion. Our outcome variables were: worry or stress about having sufficient money to pay the rent or mortgage and to purchase nutritious meals. We conducted a two-stage least squares instrumental variables regression. RESULTS A 10%-point increase in the proportion of those who obtained health insurance following the ACA Medicaid expansion reduced the probability of being worried and stressed related to purchasing nutritious meals by 7.2% points (95% CI: 1.3-13.2) as well as paying the rent or mortgage by 8.6% points (95% CI: 2.5-14.7) among people living below 138% of the federal poverty level (FPL). The ACA Medicaid expansion was not associated with access to health insurance among those living over 138% of FPL, and obtaining health insurance did not influence stress or worry in relation to affording rent/mortgage or meals in this income group. CONCLUSIONS Improved access to health insurance contributed to reducing worry and stress associated with paying rent/mortgage or purchasing meals among low-income people. Expanding health insurance access may have contributed to increasing the disposable income of low income groups.
Collapse
Affiliation(s)
- Shiho Kino
- Department of Social and Behavioral Sciences, Harvard. T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Koryu Sato
- Department of Social and Behavioral Sciences, Harvard. T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard. T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| |
Collapse
|