Early Marketplace Enrollees Were Older And Used More Medication Than Later Enrollees; Marketplaces Pooled Risk

Health reform under the patient protection and Affordable Care Act: characteristics of exchange-based health insurance enrollees

The Affordable Care Act (ACA) reformed and expanded healthcare coverage with an exchange-based health insurance program. While millions of Americans have benefited from enrollment in ACA marketplace insurance plans, many individuals are likely to be affected by potential future policy changes. Since few studies on the features of marketplace enrollees exist, we adopted a retrospective, cross-sectional study design using 2016 National Health Interview data to identify sociodemographic and health characteristics of enrollees, comparing them to those without insurance. Chi-square tests and logistic regression examined factors associated with enrollees. Adults with multiple chronic diseases (AOR = 1.90, 95% CI = 1.44, 2.50), a history of smoking (AOR = 2.44, 95% CI = 1.82, 3.26), females, married, age 50-64 years, higher educational attainment, and retirees (AOR = 1.86, 95% CI = 1.06, 3.27) were more likely to be enrollees. Since enrollees are largely higher risk individuals with greater healthcare needs, policies that modify the ACA should take these factors into account to reduce potential adverse impacts on enrollees.

What should health insurance cover? A comparison of Israeli and US approaches to benefit design under national health reform

What health insurance should cover and pay for represents one of the most complex questions in national health policy. Israel shares with the US reliance on a regulated insurance market and we compare the approaches of the two countries regarding determining health benefits. Based on review and analysis of literature, laws and policy in the United States and Israel. The Israeli experience consists of selection of a starting point for defining coverage; calculating the expected cost of covered benefits; and creating a mechanism for updating covered benefits within a defined budget. In implementing the Affordable Care Act, the US rejected a comprehensive and detailed approach to essential health benefits. Instead, federal regulators established broadly worded minimum standards that can be supplemented through more stringent state laws and insurer discretion. Notwithstanding differences between the two systems, the elements of the Israeli approach to coverage, which has stood the test of time, may provide a basis for the United States as it renews its health reform debate and considers delegating decisions about coverage to the states. Israel can learn to emulate the more forceful regulation of supplemental and private insurance that characterizes health policy in the United States.

Comparison of Specialty Medication Use for Common Chronic Inflammatory Diseases Among Health Exchange and Other Commercially Insured Members

BACKGROUND

The Affordable Care Act of 2010 allows the purchase of health insurance through special marketplaces called "health exchanges." The majority of individuals enrolling in the exchanges were previously uninsured, older, and sicker than other commercially insured members. Early evidence also suggests that exchange plan members use more costly specialty drugs compared with other commercially insured members.

OBJECTIVES

To (a) examine patient characteristics and specialty drug use for common chronic inflammatory diseases (CIDs) among exchange plan members compared with other commercially insured members and (b) explore variations in specialty drug use within exchange plans by metal tiers (bronze, silver, gold, and platinum), as well as across local markets.

METHODS

This analysis included adults aged ≥ 18 years who were enrolled in exchange plans (exchange population) and other commercial health plans (nonexchange population). The primary outcome was the likelihood of using specialty drugs prescribed to treat common CIDs, such as rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, psoriatic arthritis, and psoriasis. The adjusted likelihood of using CID specialty drugs was calculated from logistic regression controlling for prevalence of CIDs and other health risk factors.

RESULTS

A total of 931,384 exchange plan members and 2,682,855 nonexchange plan members were included in the analysis. Compared with the nonexchange population, the exchange population was older, more likely to be female, had more comorbid conditions, but filled fewer prescriptions. The 2 groups were similar in terms of CID prevalence. The observed likelihood of CID specialty drug use was 20.0% lower in the exchange versus the nonexchange populations (341 users per 100,000 exchange members vs. 427 users per 100,000 nonexchange members; P < 0.001). Within the exchange population, the observed likelihood of CID specialty drug use was 132 per 100,000 bronze plan members (69.1% lower than nonexchange); 326 per 100,000 silver plan members (23.5% lower than nonexchange); 579 per 100,000 gold plan members (35.6% higher than nonexchange); and 672 per 100,000 platinum plan members (57.5% higher than nonexchange). All differences were statistically significant at P < 0.001. There were also large differences by local market, ranging from 49.1% lower to 75.8% higher CID use in the exchange population than in the nonexchange population. After adjustment, the exchange population was 16.6% less likely to use CID specialty drugs than the nonexchange population (P < 0.001). Large variation in specialty drug use within the exchange plan metal tiers was reduced. After adjustment, the higher use of CID specialty drugs among the exchange population in certain local plans was no longer statistically significant.

CONCLUSIONS

Members insured through exchange plans were older and sicker than those with nonexchange plans, but they did not use more CID specialty drugs compared with the nonexchange population. Large variations were seen among the exchange plan metal tiers and by local markets, which were often related to the risk profiles of exchange plan enrollees.

DISCLOSURES

Funding for this study was provided by Anthem. Anthem had no role in study design, data interpretation, manuscript development, or the decision to publish. Chen, Gautam, DeVries, and Sylwestrzak are employees of HealthCore, a wholly owned subsidiary of Anthem. Richards is an employee of Anthem. Ruggieri is a former employee of Anthem and a current employee of MedImpact Healthcare Systems. Study concept and design were contributed by Ruggieri, Richards, DeVries, and Sylwestrzak. Chen took the lead in data collection, along with Gautam. Data interpretation was performed by Chen, along with the other authors. The manuscript was written by Chen, Gautam, Sylwestrzak, and DeVries and revised by Chen, Gautam, and Sylwestrzak, along with the other authors.

Constraints on Formulary Design Under the Affordable Care Act

I study the effect of prescription drug essential health benefits (EHB) requirements from the Affordable Care Act on prescription drug formularies of health insurance marketplace plans. The EHB regulates the number of drugs covered but leaves other dimensions (cost sharing and utilization management) of the formulary unregulated. Using data on almost all formularies in the country, I demonstrate that requiring insurers to cover one additional drug adds 0.22 drugs (3.3%) to the average formulary, mostly owing to firms increasing the number of drugs covered to comply with the EHB requirement. The EHB requirement also increases the probability that a drug is subject to utilization management and is assigned to a higher (more costly) formulary tier. My results suggest that newly covered drugs are 22.3 percentage points more likely to be subject to utilization management, compared to 36.7% for the average covered drug. Using formularies for Medicare Advantage plans, which are subject to uniform, nationwide benefit design standards, and the formulary status of newly approved drugs that do not satisfy the EHB requirement, I reject the hypotheses that consumer demand or effects on plan entry can explain my results. Copyright © 2017 John Wiley & Sons, Ltd.

Gain in Insurance Coverage and Residual Uninsurance Under the Affordable Care Act: Texas, 2013-2016

OBJECTIVES

To examine the effects of the Affordable Care Act's (ACA's) Marketplace on Texas residents and determine which population subgroups benefited the most and which the least.

METHODS

We analyzed insurance coverage rates among nonelderly Texas adults using the Health Reform Monitoring Survey-Texas from September 2013, just before the first open enrollment period in the Marketplace, through March 2016.

RESULTS

Texas has experienced a roughly 6-percentage-point increase in insurance coverage (from 74.7% to 80.6%; P = .012) after implementation of the major insurance provisions of the ACA. The 4 subgroups with the largest increases in adjusted insurance coverage between 2013 and 2016 were persons aged 50 to 64 years (12.1 percentage points; P = .002), Hispanics (10.9 percentage points; P = .002), persons reporting fair or poor health status (10.2 percentage points; P = .038), and those with a high school diploma as their highest educational attainment (9.2 percentage points; P = .023).

CONCLUSIONS

Many population subgroups have benefited from the ACA's Marketplace, but approximately 3 million Texas residents still lack health coverage. Adopting the ACA's Medicaid expansion is a means to address the lack of coverage.

Current and (Potential) Future Effects of the Affordable Care Act on HIV Prevention

Recent advances in science, program, and policy could better position the nation to achieve its vision of the USA as a place where new HIV infections are rare. Among these developments, passage of the Patient Protection and Affordable Care Act (ACA) in 2010 may prove particularly important, as the health system transformations it has launched offer a supportive foundation for realizing the potential of other advances, both within and beyond the clinical arena. This article summarizes opportunities to expand access to high-impact HIV prevention interventions under the ACA, examines whether available evidence indicates that these opportunities are being realized, and considers potential challenges to further gains for HIV prevention in an era of health reform. This article also highlights the new roles that HIV prevention programs and providers may assume in a health system no longer defined by fragmentation among public health, medical care, and community service providers.

Gaining Coverage Through Medicaid Or Private Insurance Increased Prescription Use And Lowered Out-Of-Pocket Spending

A growing body of literature describes how the Affordable Care Act (ACA) has expanded health insurance coverage. What is less well known is how these coverage gains have affected populations that are at risk for high health spending. To investigate this issue, we used prescription transaction data for a panel of 6.7 million prescription drug users to compare changes in coverage, prescription fills, plan spending, and out-of-pocket spending before and after the implementation of the ACA's coverage expansion. We found a 30 percent reduction in the proportion of this population that was uninsured in 2014 compared to 2013. Uninsured people who gained private coverage filled, on average, 28 percent more prescriptions and had 29 percent less out-of-pocket spending per prescription in 2014 compared to 2013. Those who gained Medicaid coverage had larger increases in fill rates (79 percent) and reductions in out-of-pocket spending per prescription (58 percent). People who gained coverage who had at least one of the chronic conditions detailed in our study saw larger decreases in out-of-pocket spending compared to those who did not have at least one condition. These results demonstrate that by reducing financial barriers to care, the ACA has increased treatment rates while reducing out-of-pocket spending, particularly for people with chronic conditions.

Applying Sequential Analytic Methods to Self-Reported Information to Anticipate Care Needs

Purpose:

Identifying care needs for newly enrolled or newly insured individuals is important under the Affordable Care Act. Systematically collected patient-reported information can potentially identify subgroups with specific care needs prior to service use.

Methods:

We conducted a retrospective cohort investigation of 6,047 individuals who completed a 10-question needs assessment upon initial enrollment in Kaiser Permanente Colorado (KPCO), a not-for-profit integrated delivery system, through the Colorado State Individual Exchange. We used responses from the Brief Health Questionnaire (BHQ), to develop a predictive model for cost for receiving care in the top 25 percent, then applied cluster analytic techniques to identify different high-cost subpopulations. Per-member, per-month cost was measured from 6 to 12 months following BHQ response.

Results:

BHQ responses significantly predictive of high-cost care included self-reported health status, functional limitations, medication use, presence of 0–4 chronic conditions, self-reported emergency department (ED) use during the prior year, and lack of prior insurance. Age, gender, and deductible-based insurance product were also predictive. The largest possible range of predicted probabilities of being in the top 25 percent of cost was 3.5 percent to 96.4 percent. Within the top cost quartile, examples of potentially actionable clusters of patients included those with high morbidity, prior utilization, depression risk and financial constraints; those with high morbidity, previously uninsured individuals with few financial constraints; and relatively healthy, previously insured individuals with medication needs.

Conclusions:

Applying sequential predictive modeling and cluster analytic techniques to patient-reported information can identify subgroups of individuals within heterogeneous populations who may benefit from specific interventions to optimize initial care delivery.