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Mobley EM, Chen G, Xu J, Edgar L, Pather K, Daly MC, Awad ZT, Parker AS, Xie Z, Suk R, Mathews S, Hong YR. Association of Medicaid expansion with 2-year survival and time to treatment initiation in gastrointestinal cancer patients: A National Cancer Database study. J Surg Oncol 2023; 128:1285-1301. [PMID: 37781956 DOI: 10.1002/jso.27456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/10/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION We evaluated whether Medicaid expansion (ME) was associated with improved 2-year survival and time to treatment initiation (TTI) among patients with gastrointestinal (GI) cancer. METHODS GI cancer patients diagnosed 40-64 years were queried from the National Cancer Database. Those diagnosed from 2010 to 2012 were considered pre-expansion; those diagnosed from 2014 to 2016 were considered post-expansion. Cox models estimated hazard ratios and 95% confidence intervals (CIs) for 2-year overall survival. Generalized estimating equations (GEE) estimated odds ratios (OR) and 95% CI of TTI within 30- and 90 days. Multivariable Difference-in-Difference models were used to compare expansion/nonexpansion cohorts pre-/post-expansion, adjusting for patient, clinical, and hospital factors. RESULTS 377,063 patients were included. No significant difference in 2-year survival was demonstrated across ME and non-ME states overall or in site-based subgroup analysis. In stage-based subgroup analysis, 2-year survival significantly improved among stage II cancer, with an 8% decreased hazard of death at 2 years (0.92; 0.87-0.97). Those with stage IV had a 4% increased hazard of death at 2 years (1.04; 1.01-1.07). Multivariable GEE models showed increased TTI within 30 days (1.12; 1.09-1.16) and 90 days (1.22; 1.17-1.27). Site-based subgroup analyses indicated increased likelihood of TTI within 30 and 90 days among colon, liver, pancreas, rectum, and stomach cancers, by 30 days for small intestinal cancer, and by 90 days for esophageal cancer. In subgroup analyses, all stages experienced improved odds of TTI within 30 and 90 days. CONCLUSION ME was not associated with significant improvement in 2-year survival for those with GI cancer. Although TTI increased after ME for both cohorts, the 30- and 90-day odds of TTI was higher for those from ME compared with non-ME states. Our findings add to growing evidence of associations with ME for those diagnosed with GI cancer.
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Affiliation(s)
- Erin M Mobley
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Guanming Chen
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jie Xu
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Lauren Edgar
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Keouna Pather
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Meghan C Daly
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Ziad T Awad
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | | | - Zhigang Xie
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
| | - Ryan Suk
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Simon Mathews
- Division of Gastroenterology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
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Dhakal P, Joshi U, Lyden E, Pyakuryal A, Gundabolu K, Bhatt VR. Association of insurance types and outcomes in acute promyelocytic leukemia. Leuk Lymphoma 2022; 63:2627-2635. [DOI: 10.1080/10428194.2022.2090554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Prajwal Dhakal
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Utsav Joshi
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Elizabeth Lyden
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Krishna Gundabolu
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vijaya Raj Bhatt
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
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Wray CM, Khare M, Keyhani S. Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US. JAMA Netw Open 2021; 4:e2110275. [PMID: 34061204 PMCID: PMC8170543 DOI: 10.1001/jamanetworkopen.2021.10275] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/24/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Contemporary data directly comparing experiences between individuals with public and private health insurance among the 5 major forms of coverage in the US are limited. Objective To compare individual experiences related to access to care, costs of care, and reported satisfaction with care among the 5 major forms of health insurance coverage in the US. Design, Setting, and Participants This survey study used data from the 2016-2018 Behavioral Risk Factor Surveillance System on 149 290 individuals residing in 17 states and the District of Columbia, representing the experiences of more than 61 million US adults. Exposure Private (individually purchased and employer-sponsored coverage) or public health insurance (Medicare, Medicaid, and Veterans Health Administration [VHA] or military coverage). Main Outcomes and Measures A pairwise multivariable analysis was performed, controlling for underlying health status of US adults covered by private and public health insurance plans, and responses to survey questions on access to care, costs of care, and reported satisfaction with care were compared. Estimates are weighted. Results A total of 149 290 individuals responded to the survey (mean [SD] age, 50.7 [0.2] years; 52.8% female). Among the respondents, most were covered by private insurance (95 396 [63.9%]), followed by Medicare (35 531 [23.8%]), Medicaid (13 286 [8.9%]), and VHA or military (5074 [3.4%]) coverage. Among those with private insurance, most (117 939 [79.0%]) had employer-sponsored coverage. Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57) and were more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17). Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64). Compared with individuals covered by Medicaid, those with employer-sponsored insurance were more likely to report having medical debt (OR, 2.06; 95% CI, 1.83-2.32) and were less likely to report difficulty seeing a physician because of costs (OR, 0.83; 95% CI, 0.73-0.95) and not taking medications because of costs (OR, 0.78; 95% CI, 0.66-0.92). No difference in satisfaction with care (OR, 0.96; 95% CI, 0.87-1.06) was found between individuals with employer-sponsored private health insurance and those with Medicaid coverage. Conclusions and Relevance In this survey study, individuals with private insurance were more likely to report poor access to care, higher costs of care, and less satisfaction with care compared with individuals covered by publicly sponsored insurance programs. These findings suggest that public health insurance options may provide more cost-effective care than private options.
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Affiliation(s)
- Charlie M. Wray
- Department of Medicine, University of California, San Francisco
- Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Meena Khare
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
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Gai Y, Jones K. Insurance patterns and instability from 2006 to 2016. BMC Health Serv Res 2020; 20:334. [PMID: 32316952 PMCID: PMC7171789 DOI: 10.1186/s12913-020-05226-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background There is a rich literature on insurance coverage and its impacts on health care. Many recent studies have examined the impacts of the Affordable Care Act (ACA) and found that it had positive effects on health insurance coverage and health care usage. Most of the literature, however, has focused on insurance coverage at a single point in time, while research on insurance instability is underrepresented, even though it could significantly impact health outcomes. The aim of this study is to examine changes and implications of insurance instability among nonelderly adults from 2006 to 2016, covering the Great Recession and post-ACA periods. Methods Using 2006-to-2016 Medical Expenditure Panel Survey data, we identify seven insurance patterns and analyze them by race/ethnicity, age, geography, income, and medical conditions. We then use multivariable linear models to analyze the relationship between insurance instability and health care status, access, and utilization. Logistic, Poisson and nonlinear models test the robustness of our results. Results The post-ACA period 2015–2016 saw the lowest ever-uninsured rate (25.68% or 67.91 million). The largest decrease in insurance instability was among adults aged 19–25, low-income families, Hispanics, the western population, and the healthy population. Like the always-uninsured, those with other insurance gaps experienced a lack of access to care and decreased preventive care and other services. Conclusions Despite the post-ACA instability reduction, over 25% of the U.S. population continued to have insurance gaps over a two-year period. Disparities continued to exist between income groups, race/ethnicities, and regions. Repealing ACA could exacerbate insurance instability and disparities between different groups, which in turn could lead to adverse health outcomes.
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Affiliation(s)
- Yunwei Gai
- Economics Division, Babson College, 231 Forest Street, Babson Park, MA, 02457-0310, USA.
| | - Kent Jones
- Economics Division, Babson College, 231 Forest Street, Babson Park, MA, 02457-0310, USA
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Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 87:491-501. [PMID: 31095067 DOI: 10.1097/ta.0000000000002368] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE Review, Economic/Decision, level III.
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Hong YR, Smith GL, Xie Z, Mainous AG, Huo J. Financial burden of cancer care under the Affordable Care Act: Analysis of MEPS-Experiences with Cancer Survivorship 2011 and 2016. J Cancer Surviv 2019; 13:523-536. [PMID: 31183677 PMCID: PMC6679733 DOI: 10.1007/s11764-019-00772-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/25/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine whether the implementation of Affordable Care Act (ACA) reduced the financial burden associated with cancer care among non-elderly cancer survivors. METHODS Using data from the MEPS-Experiences with Cancer Survivorship Survey, we examined whether there was a difference in financial burden associated with cancer care between 2011 (pre-ACA) and 2016 (post-ACA). Two aspects of financial burden were considered: (1) self-reported financial burden, whether having financial difficulties associated with cancer care and (2) high-burden spending, whether total out-of-pocket (OOP) spending incurred in excess of 10% or 20% of family income. Generalized linear regression models were estimated to adjust the OOP expenditures (reported in 2016 US dollar). RESULTS Our sample included adults aged 18-64 with a confirmed diagnosis of any cancer in 2011 (n = 655) and in 2016 (n = 490). There was no apparent difference in the prevalence of cancer survivors reporting any financial hardship or being with high-burden spending between 2011 and 2016. The mean OOP decreased by $268 (95% CI, - 384 to - 152) after the ACA. However, we found that the mean premium payments increased by $421 (95% CI, 149 to 692) in the same period. CONCLUSIONS The ACA was associated with reduced OOP for health services but increased premium contributions, resulting in no significant impact on perceived financial burden among non-elderly cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS The financial hardship of cancer survivorship points to the need for the development of provisions that help cancer patients reduce both perceived and materialized burden of cancer care under ongoing health reform.
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Affiliation(s)
- Young-Rock Hong
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA.
| | - Grace L Smith
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhigang Xie
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
| | - Arch G Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, USA
| | - Jinhai Huo
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
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Patient-centered care factors and access to care: a path analysis using the Andersen behavior model. Public Health 2019; 171:41-49. [DOI: 10.1016/j.puhe.2019.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/19/2019] [Accepted: 03/29/2019] [Indexed: 11/21/2022]
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Shifts in Medicaid and Uninsured Payer Mix at Safety-Net and Non-Safety-Net Hospitals During the Great Recession. J Healthc Manag 2018; 63:156-172. [PMID: 29734277 DOI: 10.1097/jhm-d-16-00024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
EXECUTIVE SUMMARY There has been ongoing concern regarding the viability of safety-net hospitals (SNHs), which care for vulnerable populations. The authors examined payer mix at SNHs and non-SNHs during a period covering the Great Recession using data from the 2006 to 2012 Healthcare Cost and Utilization Project State Inpatient Databases from 38 states. The number of privately insured stays decreased at both SNHs and non-SNHs. Non-SNHs increasingly served Medicaid-enrolled and uninsured patients; in SNHs, the number of Medicaid stays decreased and uninsured stays remained stable. These study findings suggest that SNHs were losing Medicaid-enrolled patients relative to non-SNHs before the Medicaid expansion under the Affordable Care Act (ACA). Postexpansion, Medicaid stays will likely increase for both SNHs and non-SNHs, but the increase at SNHs may not be as large as expected if competition increases. Because hospital stays with private insurance and Medicaid help SNHs offset uncompensated care, a lower-than-expected increase could affect SNHs' ability to care for the remaining uninsured population. Continued monitoring is needed once post-ACA data become available.
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Hong YR, Tauscher J, Cardel M. Distrust in health care and cultural factors are associated with uptake of colorectal cancer screening in Hispanic and Asian Americans. Cancer 2017; 124:335-345. [PMID: 28976535 DOI: 10.1002/cncr.31052] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/01/2017] [Accepted: 09/05/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND There are racial/ethnic disparities in colorectal cancer (CRC) screening, including lower uptake rates among Hispanic Americans (HAs) and Asian Americans (AAs) relative to non-Hispanic white Americans. The objective of this study was to explore pathways associated with the use of health services and to characterize multifaceted associations with the uptake of CRC screening among HAs and AAs. METHODS Data were obtained from the Medical Expenditure Panel Survey (2012-2013). Participants included HA (n = 3731) and AA (n = 1345) respondents ages 50 to 75 years who met CRC screening recommendations. A modified Andersen behavioral model was used to examine pathways that lead to CRC screening uptake, including predisposing characteristics (education, economic, and cultural factors), health insurance, health needs (perceived health status and several comorbidities), and health provider contextual factors (access to care, perceived quality of health services, and distrust in health care). Structural equation modeling was used to examine the models for HAs and AAs. RESULTS In the HA model, cultural factors (standardized regression coefficient [β] = -0.04; P = .013) and distrust in health care (β = -0.05; P = .007) directly and negatively affected CRC screening. Similarly, cultural factors (β = -0.11; P = .002) negatively affected CRC screening in the AA model, but distrust in health care was not significant (P = .103). In both models, perceived quality of health services was positively associated with CRC screening uptake and mediated the negative association between cultural factors and CRC screening. Access to care was not associated with CRC screening. CONCLUSIONS Correlations between CRC screening and associated factors differ among HAs and AAs, suggesting a need for multilevel interventions tailored to race/ethnicity. The current findings suggest that facilitating access to care without improving perceived quality of health services may be ineffective for increasing the uptake of CRC screening among HAs and AAs. Cancer 2018;124:335-45. © 2017 American Cancer Society.
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Affiliation(s)
- Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Justin Tauscher
- Counseling and Counselor Education, College of Education, University of Florida, Gainesville, Florida
| | - Michelle Cardel
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida
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Schokkaert E, Steel J, Van de Voorde C. Out-of-Pocket Payments and Subjective Unmet Need of Healthcare. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:545-555. [PMID: 28432643 DOI: 10.1007/s40258-017-0331-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We present a critical review of the literature that discusses the link between the level of out-of-pocket payments in developed countries and the share of people in these countries reporting that they postpone or forgo healthcare for financial reasons. We discuss the pros and cons of measuring access problems with this subjective variable. Whereas the quantitative findings in terms of numbers of people postponing care must be interpreted with utmost caution, the picture for the vulnerable groups in society is reasonably robust and unsurprising: people with low incomes and high morbidity and incomplete (or non-existent) insurance coverage are most likely to postpone or forgo healthcare for financial reasons. It is more surprising that people with high incomes and generous insurance coverage also report that they postpone care. We focus on some policy-relevant issues that call for further research: the subtle interactions between financial and non-financial factors, the possibility of differentiation of out-of-pocket payments between patients and between healthcare services, and the normative debate around accessibility and affordability.
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Affiliation(s)
- Erik Schokkaert
- Department of Economics, KU Leuven and CORE, Université catholique de Louvain, Louvain-la-Neuve, Belgium.
| | - Jonas Steel
- Department of Economics, KU Leuven, Louvain, Belgium
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Up-to-Date on Preventive Care Services Under Affordable Care Act: A Trend Analysis From MEPS 2007-2014. Med Care 2017; 55:771-780. [PMID: 28671929 DOI: 10.1097/mlr.0000000000000763] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The utilization of preventive care services has been less than optimal. As part of an effort to address this, the Affordable Care Act (ACA) mandated that private health insurance plans cover evidence-based preventive services. OBJECTIVES To evaluate whether the provisions of ACA have increased being up-to-date on recommended preventive care services among privately insured individuals aged 18-64. RESEARCH DESIGN Multivariate linear regression models were used to examine trends in prevalence of being up-to-date on selected preventive services, diagnosis of health conditions, and health expenditures between pre-ACA (2007-2010) and post-ACA (2011-2014). Adjusted difference-in-difference analyses were used to estimate changes in those outcomes in the privately insured that differed from changes in the uninsured (control group). RESULTS After the passage of ACA, up-to-date rates of routine checkup (2.7%; 95% confidence interval, 0.8%-4.7%; P=0.007) and flu vaccination (5.9%; 95% confidence interval, 4.2%-7.6%; P<0.001) increased among those with private insurance, as compared with the control group. Changes in blood pressure check, cholesterol check and cancer screening (pap smear test, mammography, and colorectal cancer screening) were not associated with the ACA. Prevalence in diagnosis of health conditions remained constant. Slower uptrends in adjusted total health care expenditures and downtrends in adjusted out-of-pocket costs were observed during the study period. CONCLUSIONS The provisions of the ACA have resulted in trivial increases in being up-to-date on selected preventive care services. Additional efforts may be required to take full advantage of the elimination of cost-sharing under the ACA.
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