From the Affordable Care Act to Affordable Care

Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States

BACKGROUND & AIMS

Liver disease is associated with substantial morbidity and mortality, likely incurring financial distress (i.e. healthcare affordability and accessibility issues), although long-term national-level data are limited.

METHODS

Using the National Health Interview Survey from 2004 to 2018, we categorised adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and Cox regression were used to assess the association of liver disease with financial distress and financial distress with all-cause mortality, respectively.

RESULTS

Among adults with liver disease (n = 19,407) vs. those without liver disease (n = 996,352), those with cancer history (n = 37,225), those with emphysema (n = 7,937), and those with coronary artery disease (n = 21,510), the age-adjusted proportion reporting healthcare affordability issues for medical services was 29.9% (95% CI 29.7-30.1%) vs. 18.1% (95% CI 18.0-18.3%), 26.5% (95% CI 26.3-26.7%), 42.2% (95% CI 42.1-42.4%), and 31.6% (31.5-31.8%), respectively, and for medications: 15.5% (95% CI 15.4-15.6%) vs. 8.2% (95% CI 8.1-8.3%), 14.8% (95% CI 14.7-14.9%), 26.1% (95% CI 26.0-26.2%), and 20.6% (95% CI 20.5-20.7%), respectively. In multivariable analysis, liver disease (vs. without liver disease, vs. cancer history, vs. emphysema, and vs. coronary artery disease) was associated with inability to afford medical services (adjusted odds ratio [aOR] 1.84, 95% CI 1.77-1.92; aOR 1.32, 95% CI 1.25-1.40; aOR 0.91, 95% CI 0.84-0.98; and aOR 1.11, 95% CI 1.04-1.19, respectively) and medications (aOR 1.92, 95% CI 1.82-2.03; aOR 1.24, 95% CI 1.14-1.33; aOR 0.81, 95% CI 0.74-0.90; and aOR 0.94, 95% CI 0.86-1.02, respectively), delays in medical care (aOR 1.77, 95% CI 1.69-1.87; aOR 1.14, 95% CI 1.06-1.22; aOR 0.88, 95% CI 0.79-0.97; and aOR 1.05, 95% CI 0.97-1.14, respectively), and not receiving the needed medical care (aOR 1.86, 95% CI 1.76-1.96; aOR 1.16, 95% CI 1.07-1.26; aOR 0.89, 95% CI 0.80-0.99; aOR 1.06, 95% CI 0.96-1.16, respectively). In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality (aHR 1.24, 95% CI 1.01-1.53).

CONCLUSIONS

Adults with liver disease face greater financial distress than adults without liver disease and adults with cancer history. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritised in this population.

IMPACT AND IMPLICATIONS

Adults with liver disease use many medical services, but long-term national studies regarding the financial repercussions and the effects on mortality for such patients are lacking. This study shows that adults with liver disease are more likely to face issues affording medical services and prescription medication, experience delays in medical care, and needing but not obtaining medical care owing to cost, compared with adults without liver disease, adults with cancer history, are equally likely as adults with coronary artery disease, and less likely than adults with emphysema-patients with liver disease who face these issues are at increased risk of death. This study provides the impetus for medical providers and policymakers to prioritise interventions to improve healthcare affordability for adults with liver disease.

Health Savings Accounts No Longer Promote Consumer Cost-Consciousness

Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.

How Well Do Results From Randomized Clinical Trials and/or Recommendations for Implantable Cardioverter-Defibrillator Programming Diffuse Into Clinical Practice?Translation Assessed in a National Cohort of Patients With Implantable Cardioverter-Defibrillators ( ALTITUDE )

Background Inappropriate implantable cardioverter-defibrillator programming can be detrimental. Whether trials/recommendations informing best implantable cardioverter-defibrillator programming (high-rate cutoff and/or extended duration of detection) influence practice is unknown. Methods and Results We measured reaction to publication of MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy; 2012) and the Consensus Statement (2015) providing generic programming parameters, in a national cohort of implantable cardioverter-defibrillator recipients, using the ALTITUDE database (Boston Scientific). Yearly changes in programmed parameters to either trial-specified or class 1 recommended parameters (≥185 beats per minute or delay ≥6 seconds) were assessed in parallel. From 2008 to 2017, 232 982 patients (aged 67±13 years; 28% women) were analyzed. Prevalence of MADIT- RIT -specific settings before publication was <1%, increasing to 13.6% in the year following. Thereafter, this increased by <6% over 5 years. Among preexisting implants (91 171), most patients (58 739 [64.4%]) underwent at least 1 in-person device reprogramming after trial publication, but <2% were reprogrammed to MADIT - RIT settings. Notably, prevalence of programming to ≥185 beats per minute or delay ≥6 seconds was increased by MADIT - RIT (57.4% in 2013 versus 40.2% at baseline), but the following publication of recommendations had minor incremental effect (73.2% in 2016 versus 70.8% in 2015). High-rate cutoff programming was favored almost 2-fold compared with extended duration throughout the test period. Practice changes demonstrated large interhospital and interstate variations. Conclusions Trial publication had an immediate effect during 1 year postpublication, but absolute penetration was low, and amplified little with time. Consensus recommendations had a negligible effect. However, generic programming was exercised more widely, and increased after trial publication, but not following recommendations.

Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act

We examine changes in health insurance coverage and access to and utilization of health care before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) among the U.S. adult immigrant population. Data from the 2011-2016 National Health Interview Survey are used to compare adult respondents in 2011-2013 (before the ACA implementation) and 2014-2016 (after the ACA implementation). Multivariable logistic regression analyses are used to compare changes over time. This study shows that the ACA has closed the coverage gap that previously existed between U.S. citizens and non-citizen immigrants. We find that naturalized citizens, non-citizens with more than 5 years of U.S. residency, and non-citizens with 5 years or less of U.S. residency reduced their probability of being uninsured by 5.81, 9.13, and 8.23%, respectively, in the first 3 years of the ACA. Improvements in other measures of access and utilization were also observed.

Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act

The Affordable Care Act (ACA) aims to expand health insurance coverage and minimize financial barriers to receiving health care services for individuals. However, little is known about how the ACA has impacted individuals with mental health conditions. This study finds that the implementation of the ACA is associated with an increase in rate of health insurance coverage among nonelderly adults with serious psychological distress (SPD) and a reduction in delaying and forgoing necessary care. The ACA also reduced the odds of an individual with SPD not being able to afford mental health care. Mental health care access among racial and ethnic minority populations and people with low income has improved during 2014-2016, but gaps remain.

Lower barriers to primary care after the implementation of the Affordable Care Act in the United States of America

OBJECTIVE

To examine short-term changes in perceived barriers to access to primary care before and after implementation of the Affordable Care Act (ACA) among adults in the United States of America.

METHODS

The ACA was approved in 2010. We used the National Health Interview Survey (NHIS) for the years 2011-2014 to compare the main reported problems in accessing primary care among adult respondents in 2011-2013 (before implementation of mandatory ACA health insurance for individuals) and in 2014 (after that implementation). A multivariate logistic stepwise regression analysis was used to identify trends with primary care barriers.

RESULTS

We found that from 2010 through 2014, individuals were progressively less likely to report challenges to accessing care, such as having trouble finding a provider, getting accepted as new patients, and health care providers not accepting their health insurance. In addition, adults were less likely to report inconveniences linked to waiting times for an appointment and with provider's office hours.

CONCLUSIONS

Informing policymakers, providers, and system administrators about the short-term changes in perceived barriers to care offers a baseline for evaluating policies and programs linked to implementing the ACA, as well as assessing how prepared primary care networks were for the influx of newly insured patients. Nevertheless, the abolition of the ACA health insurance mandate through legislation approved in December 2017 has put into question whether patients' perceptions of improved access to care will be sustained in the future.

The Affordable Care Act Attenuates Financial Strain According to Poverty Level

We use data from the 2011-2016 National Health Interview Survey to examine how the Patient Protection and Affordable Care Act (ACA) has influenced disparities in health care-related financial strain, access to care, and utilization of services by categories of the Federal Poverty Level (FPL). We use multivariable regression analyses to determine the ACA's effects on these outcome measures, as well as to determine how changes in these measures varied across different FPL levels. We find that the national implementation of the ACA's insurance expansion provisions in 2014 was associated with improvements in health care-related financial strain, access, and utilization. Relative to adults earning more than 400% of the FPL, the largest effects were observed among those earning between 0% to 124% and 125% to 199% of the FPL after the implementation of the ACA. Both groups experienced reductions in disparities in financial strain and uninsurance relative to the highest FPL group. Overall, the ACA has attenuated health care-related financial strain and improved access to and the utilization of health services for low- and middle-income adults who have traditionally not met income eligibility requirements for public insurance programs. Policy changes that would replace the ACA with less generous age-based tax subsidies and reductions in Medicaid funding could reverse these gains.

Treatment use, sources of payment, and financial barriers to treatment among individuals with opioid use disorder following the national implementation of the ACA

INTRODUCTION

Despite increasing rates of opioid misuse and hospitalizations, rates of treatment for those with opioid use disorder (OUD) are very low. This study examined the impact of the Patient Protection and Affordable Care Act's (ACA) insurance expansion on improving rates of insurance, health care access, and treatment for those with OUD.

METHODS

Data on individuals ages 18-64 with OUD come from the 2008-2014 National Survey on Drug Use and Health (N=4100). Multivariable logistic regression analyses were performed to estimate the trends of health care insurance, treatment and barriers to care across the stages of ACA implementation: pre-ACA (2008-2009), partial-ACA (2010-2013), and national implementation (2014). All models were adjusted for predisposing, enabling, and need factors.

RESULTS

In both adjusted and unadjusted comparisons, national implementation of the ACA was associated with significant improvements in outcome measures for those with OUD. Multivariable analyses indicate that, after national implementation, those with OUD were significantly less likely to be uninsured and were less likely to report financial barriers as a reason for not receiving substance use treatment, relative to the pre-ACA period. Individuals were also more likely to receive substance use treatment and were more likely to report that insurance paid for treatment after national implementation of the ACA relative to the pre-ACA period. These results persisted when national implementation was compared relative to partial-implementation.

CONCLUSIONS

National implementation of the ACA has helped to reduce rates of uninsurance, barriers to care, and improve rates of substance use treatment for those with OUD.

Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act

OBJECTIVE

To examine racial and ethnic disparities in health care access and utilization after the Affordable Care Act (ACA) health insurance mandate was fully implemented in 2014.

RESEARCH DESIGN

Using the 2011-2014 National Health Interview Survey, we examine changes in health care access and utilization for the nonelderly US adult population. Multivariate linear probability models are estimated to adjust for demographic and sociodemographic factors.

RESULTS

The implementation of the ACA (year indicator 2014) is associated with significant reductions in the probabilities of being uninsured (coef=-0.03, P<0.001), delaying any necessary care (coef=-0.03, P<0.001), forgoing any necessary care (coef=-0.02, P<0.001), and a significant increase in the probability of having any physician visits (coef=0.02, P<0.001), compared with the reference year 2011. Interaction terms between the 2014 year indicator and race/ethnicity demonstrate that uninsured rates decreased more substantially among non-Latino African Americans (African Americans) (coef=-0.04, P<0.001) and Latinos (coef=-0.03, P<0.001) compared with non-Latino whites (whites). Latinos were less likely than whites to delay (coef=-0.02, P<0.001) or forgo (coef=-0.02, P<0.001) any necessary care and were more likely to have physician visits (coef=0.03, P<0.005) in 2014. The association between year indicator of 2014 and the probability of having any emergency department visits is not significant.

CONCLUSIONS

Health care access and insurance coverage are major factors that contributed to racial and ethnic disparities before the ACA implementation. Our results demonstrate that racial and ethnic disparities in access have been reduced significantly during the initial years of the ACA implementation that expanded access and mandated that individuals obtain health insurance.