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Lee A, Vabson B. The value of improving insurance quality: Evidence from long-run Medicaid attrition. J Health Econ 2024; 94:102865. [PMID: 38359586 DOI: 10.1016/j.jhealeco.2024.102865] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024]
Abstract
The US government increasingly provides public health insurance coverage through private firms. We examine associated welfare implications for beneficiaries, using a 'revealed preference' framework based on beneficiaries' program attrition rates. Focusing on the Medicaid program in New York State, we exploit quasi-random variation in the initial assignment at birth to public versus private Medicaid based on birth weight. We find that infants assigned to private Medicaid at birth are less likely to subsequently leave Medicaid. We provide suggestive evidence that reduced attrition reflects beneficiary responses to improved program quality, rather than alternative mechanisms such as private Medicaid plans reducing re-enrollment barriers.
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Affiliation(s)
- Ajin Lee
- Department of Economics, Michigan State University, United States of America.
| | - Boris Vabson
- Department of Health Care Policy, Harvard Medical School, United States of America.
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2
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Tait M, Pando C, McGuire C, Perez-Sanz S, Baum L, Fowler E, Gollust S. Picturing the populations who could benefit from health insurance access expansions: An analysis of US health insurance television ads airing in 2018. World Med Health Policy 2023; 15:336-355. [PMID: 38106846 PMCID: PMC10722961 DOI: 10.1002/wmh3.549] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/14/2022] [Indexed: 11/08/2022]
Abstract
Efforts to expand access to health insurance in the United States are key to addressing health inequities and ensuring that all individuals have access to health care during the coronavirus disease 2019 pandemic. Yet, attempts to expand public insurance programs, including Medicaid, continue to face opposition in state and federal policymaking. Limited policy success raises questions about the health insurance information environment and the extent that available information signals both available resources and the need for policy reform. In this study, we explore one way that consumers and policymakers learn about health insurance-television advertisements-and analyze content in ads that could contribute to an understanding of who needs health insurance or who deserves to benefit from policies to expand insurance access. Specifically, we implement a content analysis of health insurance ads airing throughout 2018 on broadcast television or national cable, focusing on the depictions of people in those ads. Our findings indicate that individuals depicted in ads for Medicaid plans differ from those in ads for non-Medicaid plans. Groups that comprise large populations of current Medicaid enrollees, children and pregnant people, were more likely to appear in ads for non-Medicaid plans than in ads for Medicaid plans. This has implications for potential enrollees' understanding of who is eligible as well as the general public's and policymakers' perspectives on who should be targeted for current or future policies.
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Affiliation(s)
- Margaret Tait
- University of Minnesota School of Public Health, Division of Health Policy and Management, Minneapolis, Minnesota, USA
| | - Cynthia Pando
- University of Minnesota School of Public Health, Division of Health Policy and Management, Minneapolis, Minnesota, USA
| | - Cydney McGuire
- Indiana University Paul H. O’Neill School of Public and Environmental Affairs, Bloomington, Indiana, USA
| | | | - Laura Baum
- Wesleyan Media Project, Middletown, Connecticut, USA
| | - Erika Fowler
- Department of Government, Wesleyan University, Middletown, Connecticut, USA
| | - Sarah Gollust
- University of Minnesota School of Public Health, Division of Health Policy and Management, Minneapolis, Minnesota, USA
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3
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Snowden LR, Wallace N, Graaf G. Subsidized Marketplace Purchases Reduced Racial Disparities in Private Coverage Under the Affordable Care Act. J Racial Ethn Health Disparities 2023; 10:141-148. [PMID: 35032008 PMCID: PMC8760123 DOI: 10.1007/s40615-021-01204-3] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/11/2021] [Accepted: 12/03/2021] [Indexed: 02/03/2023]
Abstract
The Affordable Care Act's Marketplaces, by allowing subsidized purchase of insurance coverage by persons with incomes from the poverty line to middle income, and through active outreach and enrollment assistance efforts, are well situated to reduce large African American-white private coverage disparities. Using data from the National Health Interview Survey for multiyear periods before and after Affordable Care Act implementation, from 2011-2013 to 2015-2018, this study assessed how much disparity reduction occurred when Marketplaces were implemented. Analysis compared private coverage take-up by African Americans and whites for persons with incomes between 100 and 400% of the Federal Poverty Line (FPL), controlling for African American-white income differences and other covariates. African Americans' gains were significantly greater than whites' and disparities did close. However, both groups gained considerably less coverage than they might have, and some disparity remained. To make ongoing operations more effective and to guide future subsidy extensions and increases as enacted in the American Rescue Plan, more research is needed into the incentive value of subsidies and to discover which Marketplace outreach and enrollment assistance efforts were most effective. In advancing these aims, high priority should be given to identifying strategies that were particularly successful in reaching and engaging uninsured African Americans.
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Affiliation(s)
- Lonnie R Snowden
- School of Public Health, University of California, Berkeley, 2121 Berkeley Way, Room 5302, Berkeley, CA, 94720-7360, USA
| | - Neal Wallace
- OHSU-PSU School of Public Health, Portland State University, 1805 SW 4th Ave 523E, Portland, OR, 97201, USA
| | - Genevieve Graaf
- School of Social Work, University of Texas, Arlington, 211 S. Cooper St., Arlington, TX, 76017, USA.
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Dourgnon P, Jusot F, Marsaudon A, Sarhiri J, Wittwer J. Just a question of time? Explaining non-take-up of a public health insurance program designed for undocumented immigrants living in France. Health Econ Policy Law 2023; 18:32-48. [PMID: 35927936 DOI: 10.1017/S1744133122000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
State Medical Aid is a public health insurance program that allows undocumented immigrants with low financial resources to access health care services for free. However, the low take-up rate of this program might threaten its efficiency. The purpose of this study is therefore to provide the determinants of such a low take-up rate. To this end, we rely on the Premier Pas survey. This is an original representative sample of undocumented immigrants attending places of assistance to vulnerable populations in France. Determinants of State Medical Aid take-up are analyzed through probit and Cox modeling. The results show that only 51% of those who are eligible for the State Medical Aid program are actually covered, and this proportion is higher among women than among men. The length of stay in France is the most important determinant of take-up. It is worth noting that State Medical Aid take-up is not associated with chronic diseases or functional limitations and is negatively associated with poor mental health. There is, therefore, mixed evidence of health selection into the program. Informational barriers and vulnerabilities experienced by undocumented immigrants are likely to explain this low take-up.
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Sacarny A, Baicker K, Finkelstein A. Out of the Woodwork: Enrollment Spillovers in the Oregon Health Insurance Experiment. Am Econ J Econ Policy 2022; 14:273-295. [PMID: 36259049 PMCID: PMC9576198 DOI: 10.1257/pol.20200172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
We analyze the impact of expanded adult Medicaid eligibility on the enrollment of already-eligible children. We analyze the 2008 Oregon Medicaid lottery, in which some low-income uninsured adults were randomly selected to be allowed to apply for Medicaid. Children in these households were eligible for Medicaid irrespective of the lottery outcome. We estimate statistically significant but transitory impacts of adult lottery selection on child Medicaid enrollment: at three months after the lottery, for every 9 adults who enrolled in Medicaid due to winning the lottery, one additional child also enrolled. Our results shed light on the existence, magnitude, and nature of so-called "woodwork effects".
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Affiliation(s)
- Adam Sacarny
- Department of Health Policy and Management, Columbia University
Mailman School of Public Health, 722 West 168 Street, New York,
NY 10032, NBER, and J-PAL
| | - Katherine Baicker
- Harris School of Public Policy, University of Chicago, 1307 East
60 Street, Chicago, IL 60637, NBER, and J-PAL
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Yokum D, Hopkins DJ, Feher A, Safran E, Peck J. Effectiveness of Behaviorally Informed Letters on Health Insurance Marketplace Enrollment. JAMA Health Forum 2022; 3:e220034. [PMID: 35977283 PMCID: PMC8903125 DOI: 10.1001/jamahealthforum.2022.0034] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/12/2022] [Indexed: 11/20/2022] Open
Abstract
Question How much do behaviorally informed letters increase health insurance enrollment? Findings In this randomized clinical trial that included 744 510 individuals on the HealthCare.gov platform during the final 2 weeks of the 2015 open enrollment period, use of a single behaviorally informed letter caused a statistically significant increase in health insurance enrollment. Letters that used action language caused larger effects, particularly among Black and Hispanic individuals in Medicaid expansion states. Meaning Policy makers can use low-cost letter nudges to increase enrollment across Affordable Care Act marketplaces. Importance Every year during the open enrollment period, hundreds of thousands of individuals across the Affordable Care Act marketplaces begin the enrollment process but fail to complete it, thereby resulting in coverage gaps or going uninsured. Objective To investigate if low-cost ($0.55 per person) letters can increase health insurance enrollment. Design, Setting, and Participants This intent-to-treat randomized clinical trial was conducted during the final 2 weeks of the 2015 open enrollment period among the 37 states on the HealthCare.gov platform. The trial targeted 744 510 individuals who started the enrollment process but had yet to complete it. Data were analyzed from January through August 2021. Interventions Study participants were randomized to either a no-letter control group or to 1 of 8 letter variants that drew on evidence from the behavioral sciences about what motivates individuals to take action. Main Outcomes and Measures The primary outcome was the health insurance enrollment rate at the end of the open enrollment period. Results Of the 744 510 individuals (mean [SD] age, 41.9 [19.6] years; 53.9% women), 136 122 (18.3%) were in the control group and 608 388 (81.7%) were in the treatment group. Most lived in Medicaid nonexpansion states (72.7%), and a plurality were between 30 and 50 years old (41.0%). For race and ethnicity, 3.0% self-identified as Asian, 14.0% as Black, 5.1% as Hispanic, 39.8% as non-Hispanic White, and 38.2% as other or unknown. By the end of the open enrollment period, 4.0% of the control group enrolled in health insurance coverage. Comparatively, the enrollment rate in the pooled treatment group was 4.3%, which demonstrated an increase of 0.3 percentage points (95% CI, 0.2-0.4 percentage points; P<.001), yielding 1753 marginal enrollments. Letters that used action language caused larger enrollment effects, particularly among Black individuals (increase of 1.6 percentage points; 95% CI, 0.6-2.7 percentage points; P = .003) and Hispanic individuals (increase of 1.5 percentage points; 95% CI, 0.0-3.0 percentage points; P = .046) in Medicaid expansion states. Conclusions and Relevance This randomized clinical trial shows that letters designed with best practices from the behavioral sciences literature were a low-cost way to increase health insurance enrollment in the Affordable Care Act marketplaces. More research is needed to understand what messages are most effective amid the recently passed American Rescue Plan. Trial Registration ClinicalTrials.gov Identifier: NCT05010395
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Affiliation(s)
| | | | | | - Elana Safran
- Office of Evaluation Sciences, US General Services Administration, Washington, DC
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7
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Myerson R, Tilipman N, Feher A, Li H, Yin W, Menashe I. Personalized Telephone Outreach Increased Health Insurance Take-Up For Hard-To-Reach Populations, But Challenges Remain. Health Aff (Millwood) 2022; 41:129-137. [PMID: 34982628 PMCID: PMC8844881 DOI: 10.1377/hlthaff.2021.01000] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We tested the impact of personalized telephone calls from service center representatives on health plan enrollment in California's Affordable Care Act Marketplace, Covered California, using a randomized controlled trial. The study sample included 79,522 consumers who had applied but not selected a plan. Receiving a call increased enrollment by 2.7 percentage points (22.5 percent) overall. Among subgroups, receiving a call significantly increased enrollment among consumers with income below 200 percent of the federal poverty level (4.0 percentage points or 47.6 percent for consumers with incomes below 150 percent of poverty and 4.0 percentage points or 36.4 percent for consumers with incomes of 150-199 of poverty), as well as those who were referred from Medicaid (2.9 percentage points or 53.7 percent), those ages 30-50 (2.4 percentage points or 23.3 percent) or older than age 50 (5.1 percentage points or 34.2 percent), those who were Hispanic (2.3 percentage points or 31.1 percent), and those whose preferred spoken language was Spanish (3.2 percentage points or 74.4 percent) or English (2.6 percentage points or 18.6 percent). The intervention provided a two-to-one return on investment. Yet absolute enrollment in the target population remained low; persistent enrollment barriers may have limited the intervention's impact. These findings inform implementation of the American Rescue Plan Act of 2021, which expands eligibility for subsidized coverage.
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Affiliation(s)
- Rebecca Myerson
- Rebecca Myerson, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nicholas Tilipman
- Nicholas Tilipman, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew Feher
- Andrew Feher, Covered California, Sacramento, California
| | - Honglin Li
- Honglin Li, University of Wisconsin-Madison
| | - Wesley Yin
- Wesley Yin, University of California Los Angeles, Los Angeles, California
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Baillon A, Capuno J, O'Donnell O, Tan CA, van Wilgenburg K. Persistent effects of temporary incentives: Evidence from a nationwide health insurance experiment. J Health Econ 2022; 81:102580. [PMID: 34986436 DOI: 10.1016/j.jhealeco.2021.102580] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Abstract
Temporary incentives are offered in anticipation of persistent effects that are seldom estimated. We use a nationwide randomized experiment in the Philippines to estimate effects of two incentives for health insurance three years after their withdrawal. We find that both temporary incentives had persistent effects on enrollment. A premium subsidy had a small but highly persistent effect. Application assistance offered to those initially unresponsive to the subsidy had a much larger but less persistent effect. The subsidy persuaded those with higher initial stated willingness to pay to enroll and keep enrolling. The offer of application assistance to initial non-compliers with the subsidy achieved a larger immediate effect by drawing in those who stated they valued insurance less and were less likely to re-enroll when the incentives were withdrawn.
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Affiliation(s)
- Aurélien Baillon
- Erasmus School of Economics, Erasmus University Rotterdam, Tinbergen Institute Netherlands.
| | - Joseph Capuno
- School of Economics, University of the Philippines Diliman Philippines.
| | - Owen O'Donnell
- Erasmus School of Economics, Erasmus University Rotterdam, Tinbergen Institute Netherlands; Faculty of Economics and Business, University of Lausanne, Switzerland; Erasmus School of Health Policy and Management, Erasmus University Rotterdam Netherlands.
| | | | - Kim van Wilgenburg
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam Netherlands.
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Chevalier JA, Schwartz JL, Su Y, Williams KR. JUE Insight: Distributional Impacts of Retail Vaccine Availability. J Urban Econ 2022; 127:103382. [PMID: 34538973 PMCID: PMC8437756 DOI: 10.1016/j.jue.2021.103382] [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] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/19/2021] [Indexed: 06/13/2023]
Abstract
We examine the potential for exploiting retailer location choice in targeting health interventions. Using geospatial data, we quantify proximity to vaccines created by a U.S. federal program distributing COVID-19 vaccines to commercial retail pharmacies. We assess the distributional impacts of a proposal to provide vaccines at Dollar General, a low-priced general merchandise retailer. Adding Dollar General to the federal program would substantially decrease the distance to vaccine sites for low-income, rural, and minority U.S. households, groups for which COVID-19 vaccine take-up has been disproportionately slow.
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Affiliation(s)
| | | | - Yihua Su
- Yale School of Public Health United States
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10
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Brown T, Rowe TA, Lee JY, Petito LC, Chmiel R, Ciolino JD, Doctor J, Fox C, Goldstein N, Kaiser D, Linder JA, Meeker D, Peprah Y, Persell SD. Design of Behavioral Economic Applications to Geriatrics Leveraging Electronic Health Records (BEAGLE): A pragmatic cluster randomized controlled trial. Contemp Clin Trials 2022; 112:106649. [PMID: 34896294 PMCID: PMC8724916 DOI: 10.1016/j.cct.2021.106649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/08/2021] [Revised: 12/01/2021] [Accepted: 12/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Overtesting and treatment of older patients is common and may lead to harms. The Choosing Wisely campaign has provided recommendations to reduce overtesting and overtreatment of older adults. Behavioral economics-informed interventions embedded within the electronic health record (EHR) have been shown to reduce overuse in several areas. Our objective is to conduct a parallel arm, pragmatic cluster-randomized trial to evaluate the effectiveness of behavioral-economics-informed clinical decision support (CDS) interventions previously piloted in primary care clinics and designed to reduce overtesting and overtreatment in older adults. METHODS/DESIGN This trial has two parallel arms: clinician education alone vs. clinician education plus behavioral-economics-informed CDS. There are three co-primary outcomes for this trial: (1) prostate-specific antigen (PSA) screening in older men, (2) urine testing for non-specific reasons in older women, and (3) overtreatment of diabetes in older adults. All eligible primary care clinics from a large regional health system were randomized using a modified constrained randomization process and their attributed clinicians were included. Clinicians were recruited to complete a survey and educational module. We randomized 60 primary care clinics with 374 primary care clinicians and achieved adequate balance between the study arms for prespecified constrained variables. Baseline annual overuse rates for the three co-primary outcomes were 25%, 23%, and 17% for the PSA, urine, and diabetes measures, respectively. DISCUSSION This trial is evaluating behavioral-economics-informed EHR-embedded interventions to reduce overuse of specific tests and treatments for older adults. The study will evaluate the effectiveness and safety of these interventions.
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Affiliation(s)
- Tiffany Brown
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Theresa A. Rowe
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ji Young Lee
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lucia C. Petito
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan Chmiel
- Northwestern Memorial HealthCare, Chicago, IL, USA
| | - Jody D. Ciolino
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jason Doctor
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, USA
| | - Craig Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, USA
| | - Noah Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Jeffrey A. Linder
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniella Meeker
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, USA
| | - Yaw Peprah
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephen D. Persell
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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11
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Ercia A, Le N, Wu R. Health insurance enrollment strategies during the Affordable Care Act (ACA): a scoping review on what worked and for whom. Arch Public Health 2021; 79:129. [PMID: 34253258 PMCID: PMC8274016 DOI: 10.1186/s13690-021-00645-w] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/21/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) provided an opportunity for millions of people in the U.S. to get coverage from the publicly funded Medicaid program or private insurance from the newly established marketplace. However, enrolling millions of people for health insurance was an enormous task. The aim of this review was to examine the strategies used to enroll people for health insurance and their effectiveness after implementing the ACA's coverage expansion. METHODS The PRISMA Extension for Scoping Review (PRISMA-ScR) guided this review. Included studies were empirical studies that met the inclusion criteria and published between 2010 and 2020. Studies were searched mainly from two scholarly databases, CINAHL Plus and Medline (PubMed) using keyword searches. Hand searches from the references of selected journals were also performed. Content analysis was conducted by two authors in which codes were inductively developed to identify themes. RESULTS There were 2213 potential studies identified from the search, but 10 met the inclusion criteria. The research design of the studies varied. Two studies were randomized trials, one quasi-experimental trial, three mixed-methods, two qualitative and two quantitative. All studies focused on strategies used to inform and help people enroll for either Medicaid or private insurance from the marketplace. This review identified three key strategies used to help enroll people for coverage: 1) individual assistance; 2) community outreach; and 3) health education and promotion (HE&P). CONCLUSION Community-based organizations were likely to use a combination of the three strategies simultaneously to reach uninsured individuals and directly help them enroll for health insurance. Other organizations that aimed to reach a wider segment of the population used single strategies, such as community outreach or HE&P.
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Affiliation(s)
- Angelo Ercia
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK.
| | - Nga Le
- Department of Health & Human Services, County of Marin, Marin, California, USA
| | - Runguo Wu
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
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12
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Bhanja A, Lee D, Gordon SH, Allen H, Sommers BD. Comparison of Income Eligibility for Medicaid vs Marketplace Coverage for Insurance Enrollment Among Low-Income US Adults. JAMA Health Forum 2021; 2:e210771. [PMID: 35977174 PMCID: PMC8796906 DOI: 10.1001/jamahealthforum.2021.0771] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022] Open
Abstract
Importance The Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option. Objective To assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado. Design Setting and Participants Using 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020. Main Outcome and Measures The main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage. Results The primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively. Conclusions and Relevance In this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.
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Affiliation(s)
- Aditi Bhanja
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Dennis Lee
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Sarah H. Gordon
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Heidi Allen
- Columbia University School of Social Work, New York, New York
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
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13
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Decker SL, Abdus S, Lipton BJ. Eligibility for and Enrollment in Medicaid Among Nonelderly Adults After Implementation of the Affordable Care Act. Med Care Res Rev 2021; 79:125-132. [PMID: 33655784 DOI: 10.1177/1077558721996851] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Affordable Care Act's (ACA) Medicaid expansion resulted in substantial gains in coverage. However, little research has documented eligibility or participation rates among eligible adults in the post-ACA period in part because of the complexities involved in assigning eligibility status. We used simulation modeling to examine Medicaid eligibility and participation during 2014 to 2017. More than one in five adults were Medicaid eligible in expansion states in the post-ACA period. In contrast, about one in 30 adults were Medicaid eligible in nonexpansion states. While eligibility rates differed substantially by expansion status, participation rates among Medicaid-eligible adults were similar in both sets of states (44% to 46%). These estimates indicate that differences in eligibility rather than in participation rates explained differences in enrollment between expansion and nonexpansion states during the study period. Participation in Medicaid is expected to grow during the coronavirus pandemic. Our study provides baseline estimates for future analyses of enrollment trends.
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Affiliation(s)
- Sandra L Decker
- Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Salam Abdus
- Agency for Healthcare Research and Quality, Rockville, MD, USA
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Gollust SE, Wilcock A, Fowler EF, Barry CL, Niederdeppe J, Baum L, Karaca-Mandic P. TV Advertising Volumes Were Associated With Insurance Marketplace Shopping And Enrollment In 2014. Health Aff (Millwood) 2018; 37:956-963. [DOI: 10.1377/hlthaff.2017.1507] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sarah E. Gollust
- Sarah E. Gollust is an associate professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota, in Minneapolis
| | - Andrew Wilcock
- Andrew Wilcock is a postdoctoral fellow in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Erika Franklin Fowler
- Erika Franklin Fowler is an associate professor in the Department of Government, Wesleyan University, in Middletown, Connecticut, and codirector of the Wesleyan Media Project
| | - Colleen L. Barry
- Colleen L. Barry is the Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Jeff Niederdeppe
- Jeff Niederdeppe is an associate professor in the Department of Communication, Cornell University, in Ithaca, New York
| | - Laura Baum
- Laura Baum is project manager of the Wesleyan Media Project in the Department of Government, Wesleyan University
| | - Pinar Karaca-Mandic
- Pinar Karaca-Mandic is an associate professor in the Finance Department and academic director of the Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota
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