A series of unfortunate events: implications of Republican efforts to repeal and replace the Affordable Care Act For older adults

Health Insurance Literacy and Medical Debt in Middle-Age Americans

BACKGROUND

Health insurance literacy (HIL) may influence medical financial burden among people who are sick and the most vulnerable.

OBJECTIVE

This study examined the relationships between HIL, health insurance factors, and medical debt among middle-age Americans, a population with an increasing prevalence of illnesses.

METHODS

Linear and generalized linear regression analyses were conducted on data drawn from the 2015-2016 waves of the Health Reform Monitoring Survey, a national, internet-based sample of Americans age 18 to 64 years. The analytical sample included 8,042 people age 50 to 64 years.

KEY RESULTS

Adjusted mean HIL scores did not differ by private versus public insurance or by out-of-pocket costs. Mean HIL scores were lower with higher deductibles; however, differences in mean scores were small. Higher HIL was associated with lower medical debt (odds ratio = 0.97; 95% confidence interval [0.96, 0.98]), but at the highest HIL score, the risk of having medical debt was still 13.8%. Public coverage, higher annual deductibles, and out-of-pocket costs were associated with higher risks of having medical debt.

CONCLUSIONS

The findings suggest that HIL plays an important role in medical debt burden. However, with the shift toward high cost-sharing insurance plans, addressing health care affordability issues along with HIL are critical to eliminate medical debt problems. [HLRP: Health Literacy Research and Practice. 2021;5(4):e319-e332.] Plain Language Summary: Understanding and using health insurance (also defined as health insurance literacy) may influence the ability to pay medical bills among people who are sick and vulnerable. This study examined the relationships among health insurance literacy, health insurance factors, and difficulty paying medical bills (i.e., medical debt) in Americans age 50 to 64 years using data from the Health Reform Monitoring Survey. People with higher health insurance literacy reported lower medical debt. Type of insurance coverage did not influence medical debt. Those with annual deductibles and out-of-pocket health care costs were more likely to report having medical debt.

Trump v. The ACA

Before his incoherent response to the COVID-19 pandemic, the focus of President Trump's health policy agenda was the elimination of the Patient Protection and Affordable Care Act (ACA), which he has called a 'disaster'. The attacks on the ACA included proposals to repeal the law through the legislative process, to erode it through a series of executive actions, and to ask the courts to declare it unconstitutional. Despite these ongoing challenges, the ACA remains largely intact as the U.S. heads into the 2020 election. The longer term fate of the law, however, is uncertain and the outcome of the 2020 election is likely to have a dramatic effect on the direction of health policy in the U.S.

Pursuing Medicaid Block Grants with the Healthy Adult Opportunity Initiative: Dressing Up Old Ideas in New Clothes

The Trump administration's Healthy Adult Opportunity waiver follows a long history of Republican attempts to retrench the Medicaid program through block grants and to markedly reduce federal spending while providing states with substantially greater flexibility over program structure. Previous block grant proposals were promulgated during the presidential administrations of Ronald Reagan and George W. Bush and majorities in Congress led by House Speaker Newt Gingrich and House Budget Committee Chair and then Speaker Paul Ryan. Most recently, Medicaid block grants featured prominently in Republican efforts to repeal and replace the Affordable Care Act. This essay traces the history of Republican Medicaid block grant proposals, culminating in the Trump administration's Healthy Adult Opportunity initiative. It concludes that the Trump administration's attempt to convert Medicaid into a block grant program through the waiver process is illegal and, if implemented, would leave thousands of people without necessary medical care. This fact, combined with failed legislative efforts to block grant Medicaid during the last forty years, highlights the substantial roadblocks to radically restructuring a popular program that helps millions of Americans.

Supports and gaps in federal policy for addressing racial and ethnic disparities among long-term care facility residents

Older adults from racial and ethnic minority groups are likely to face disparities in their health as well as care experiences in long-term care facilities such as nursing homes and assisted living facilities just as they do in the United States as a whole. Policymakers in the United States face concerns around long-term services and supports to address the growing demands of a rapidly aging population through public and private sector initiatives. It is important to create inclusive and culturally responsive environments to meet the needs of diverse groups of older adults. In spite of federal policy that supports minority health and protects the well-being of long-term care facility residents, racial and ethnic disparities persist in long-term care facilities. This manuscript describes supports and gaps in the current United States' federal policy to reduce racial and ethnic disparities in long-term care facilities. Implications for social workers are discussed and recommendations include efforts to revise portions of the Patient Protection and Affordable Care Act of 2010, amending regulations regarding long-term care facilities' training and oversight, and tailoring the Long-Term Care Ombudsman Program's data collection, analysis, and reporting requirements to include racial and ethnic demographic data.

Unmet Healthcare Needs and Healthcare Access Gaps Among Uninsured U.S. Adults Aged 50-64

Lack of health insurance (HI) is a particular problem for near-older Americans aged 50–64 because they tend to have more chronic health conditions than younger age groups and are at increased risk of disability; however, little recent research has focused on HI coverage and healthcare access among this age group. Using the U.S. National Health Interview Survey data for the years 2013 to 2018, we compared HI coverage and healthcare access between the 50–64 and 65+ age groups. Using logistic regression analysis, we then examined the sociodemographic and health characteristics of past-year healthcare access of near-older Americans without HI to those with private HI or public HI (Medicare without Medicaid, Medicaid without Medicare, Medicare and Medicaid, and VA/military HI). We estimated the odds of healthcare access among those without HI compared to those with private or public HI. Near-older Americans without HI were at least seven times more likely to have postponed or foregone needed healthcare due to costs, and only 15% to 23% as likely to have had contact with any healthcare professional in the preceding 12 months. Expanding HI to near-older adults would increase healthcare access and likely result in reduced morbidity and mortality and higher quality of life for them.

Health Insurance Affordability Concerns and Health Care Avoidance Among US Adults Approaching Retirement

IMPORTANCE

As US adults approach Medicare eligibility at age 65 years, they face important decisions about health care and employment. Recent legislative, regulatory, and legal challenges to the Affordable Care Act may add new uncertainties to this decision-making.

OBJECTIVE

To understand adults' perspectives on health insurance, health care, and employment near retirement.

DESIGN, SETTING, AND PARTICIPANTS

In October 2018, a cross-sectional online survey study of community-dwelling US adults aged 50 to 64 years was conducted with Ipsos KnowledgePanel, a nationally representative internet survey panel (completion rate, 62%). The initial data analysis was conducted from November 2018 to March 2019, and additional analyses were conducted in November 2019.

MAIN OUTCOMES AND MEASURES

Confidence in affording health insurance, keeping a job or delaying retirement to have employer-sponsored health insurance, concerns about potential changes to health insurance associated with changes in federal policies, and avoidance of medical care or medication because of cost.

RESULTS

Among 1028 respondents aged 50 to 64 years (mean [SD] age, 57.0 [4.2] years), 51.8% (95% CI, 48.6%-55.0%) were female, 40.4% (95% CI, 37.2%-43.7%) had a high school education or less, 65.2% (95% CI, 62.1%-68.3%) were employed, and 34.8% (95% CI, 31.7%-37.9%) were retired or not working. Approximately one-fourth of respondents (27.4%; 95% CI, 24.6%-30.4%) had little to no confidence in being able to afford health insurance over the next year, and nearly one-half (44.6%; 95% CI, 41.4%-47.8%) had little to no confidence in their ability to afford health insurance when they retire; 14.1% (95% CI, 12.0%-16.5%) reported keeping a job and 11.4% (95% CI, 9.6%-13.6%) reported delaying or considering delaying retirement to have employer-sponsored health insurance. Most respondents (67.7%; 95% CI, 64.6%-70.6%) were very or somewhat concerned about potential changes to their health insurance associated with changes in federal policies. In the past year, 13.2% (95% CI, 11.2%-15.5%) of respondents did not get medical care and 11.9% (95% CI, 9.9%-14.1%) avoided filling a prescription medication because of cost. After adjusting for demographic and health characteristics, individuals with low confidence in health insurance affordability during either the next year or retirement were significantly more likely than those with higher confidence to avoid medical care (adjusted odds ratio, 2.89; 95% CI, 1.86-4.49; P < .001) and to avoid filling a prescription medication (adjusted odds ratio, 2.87; 95% CI, 1.71-4.80; P < .001) because of cost concerns.

CONCLUSIONS AND RELEVANCE

Many adults aged 50 to 64 years worry about their ability to afford health insurance during retirement and about potential future changes to their health insurance options associated with changes in federal policy. Policy solutions are needed to help patients better understand their coverage options and navigate health care in this critical transition period before Medicare eligibility.

Undermining the ACA through the executive branch and federalism: what the Trump administration's approach to health reform means for older Americans

The ACA has survived multiple existential threats in the legislative and judicial branches, including dozens of congressional attempts at repeal and two major Supreme Court cases. Even as it seems that the ACA is here to stay, what the law accomplishes is far from settled. The Trump administration is using executive powers to weaken the law, in many cases using the same powers that President Obama used to strengthen the effects of the reform. States have responded by seeking flexibility to pursue reforms, such as work requirements, that could not pass Congress and that were not allowed by the Obama administration. There is no indication that the ACA is imploding as President Trump has predicted and seems to desire, although these changes have a real and substantial impact on the lives of many Americans, including the near-elderly in unique ways.