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McIntyre A, Sommers BD, Aboulafia G, Phelan J, Orav EJ, Epstein AM, Figueroa JF. Coverage and Access Changes During Medicaid Unwinding. JAMA HEALTH FORUM 2024; 5:e242193. [PMID: 38943683 PMCID: PMC11214671 DOI: 10.1001/jamahealthforum.2024.2193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/03/2024] [Indexed: 07/01/2024] Open
Abstract
Importance States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care. Objective To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states. Design, Setting, and Participants This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level. Exposure Medicaid enrollment at any point since March 2020, when continuous coverage began. Main Outcomes and Measures Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment. Results The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care. Conclusions and Relevance The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.
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Affiliation(s)
- Adrianna McIntyre
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
| | - Benjamin D. Sommers
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Gabriella Aboulafia
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
| | - Jessica Phelan
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
| | - E. John Orav
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Arnold M. Epstein
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Jose F. Figueroa
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts
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Borders TF, Thaxton Wiggins A. Cervical Cancer Screening Rates Among Rural and Urban Females, From 2019 to 2022. JAMA Netw Open 2024; 7:e2417094. [PMID: 38874926 PMCID: PMC11179126 DOI: 10.1001/jamanetworkopen.2024.17094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/16/2024] [Indexed: 06/15/2024] Open
Abstract
Importance Little nationally representative research has examined Papanicolaou testing rates from before the pandemic in 2019 through the COVID-19 pandemic in 2022. Papanicolaou testing rates among rural females are a concern as they have historically had lower screening rates than their urban counterparts. Objective To examine the receipt of a Papanicolaou test in the past year among US females overall and females residing in rural and urban areas in 2019, 2020, and 2022. Design, Setting, and Participants This repeated cross-sectional study used data from 3 years of the Health Information National Trends Survey (HINTS), a nationally representative survey that asks respondents about cancer screenings, sources of health information, and health and health care technologies. Study participants were females aged 21 to 65 years. Individuals who received a Papanicolaou test more than 1 to 3 years prior to a HINTS interview were excluded as they were likely not due for a Papanicolaou test. Exposures Survey year (2019, 2020, and 2022) and rural or urban residence were the main exposure variables. Main Outcomes and Measures Self-reported receipt of a Papanicolaou test within the past year. Results Among the 188 243 531 (weighted; 3706 unweighted) females included in the analysis, 12.5% lived in rural areas and 87.5% in urban areas. Participants had a mean (SE) age of 43.7 (0.27) years and were of Hispanic (18.8%), non-Hispanic Asian (5.2%), non-Hispanic Black (12.2%), non-Hispanic White (59.6%), or non-Hispanic other (4.1%) race and ethnicity. In 2022, unadjusted past-year Papanicolaou testing rates were significantly lower among rural vs urban residents (48.6% [95% CI, 39.2%-58.1%] vs 64.0% [95% CI, 60.0%-68.0%]; P < .001). Adjusted odds of past-year Papanicolaou testing were lower in 2022 than 2019 (odds ratio, 0.70; 95% CI, 0.52-0.95; P = .02). Conclusions and Relevance This repeated cross-sectional study found that past-year Papanicolaou testing rates were lower in 2022 than 2019, pointing to a need to increase access to screenings to prevent an uptick in cervical cancer incidence. Rural-vs-urban differences in 2022 indicate a need to specifically target rural females.
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Affiliation(s)
- Tyrone F Borders
- Center for Health Services Research, University of Kentucky, Lexington
- College of Nursing, University of Kentucky, Lexington
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Kettlewell N, Zhang Y. Age penalties and take-up of private health insurance. HEALTH ECONOMICS 2024; 33:636-651. [PMID: 38141165 DOI: 10.1002/hec.4784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 10/22/2023] [Accepted: 11/07/2023] [Indexed: 12/25/2023]
Abstract
Financial penalties for delayed enrollment could be useful tools to encourage people to enroll earlier in health insurance markets, but little is known about how effective they are. We use a large administrative dataset for a 10% random sample of all Australian tax-filers to study how people respond to a step-wise age-based penalty, and whether the effect has changed over time. Individuals must pay a 2% premium surcharge for each year they delay enrollment beyond age 31. The penalty stops after 10 years of continuous hospital cover. The age-based penalty creates discontinuities in the incentive to insure by age, which we exploit to estimate causal effects. We find that people respond as expected to the initial age-penalty, but not to subsequent penalties. The 2% premium loading results in a 0.78-3.69 percentage points (or 2.1%-9.0%) increase in the take-up rate at age 31. We simulate the penalty impact and implications of potential reforms, and conclude that modest changes around the policy make little difference in the age distribution of insured, premiums or take-up rates. Our study provides important evidence on an understudied area in the literature and offers insights for countries considering financial penalties.
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Affiliation(s)
| | - Yuting Zhang
- Melbourne Institute: Applied Economic & Social Research, Faculty of Business and Economics, University of Melbourne, Melbourne, Victoria, Australia
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Patel SY, Baum A, Basu S. Prediction of non emergent acute care utilization and cost among patients receiving Medicaid. Sci Rep 2024; 14:824. [PMID: 38263373 PMCID: PMC10805799 DOI: 10.1038/s41598-023-51114-z] [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: 10/03/2023] [Accepted: 12/30/2023] [Indexed: 01/25/2024] Open
Abstract
Patients receiving Medicaid often experience social risk factors for poor health and limited access to primary care, leading to high utilization of emergency departments and hospitals (acute care) for non-emergent conditions. As programs proactively outreach Medicaid patients to offer primary care, they rely on risk models historically limited by poor-quality data. Following initiatives to improve data quality and collect data on social risk, we tested alternative widely-debated strategies to improve Medicaid risk models. Among a sample of 10 million patients receiving Medicaid from 26 states and Washington DC, the best-performing model tripled the probability of prospectively identifying at-risk patients versus a standard model (sensitivity 11.3% [95% CI 10.5, 12.1%] vs 3.4% [95% CI 3.0, 4.0%]), without increasing "false positives" that reduce efficiency of outreach (specificity 99.8% [95% CI 99.6, 99.9%] vs 99.5% [95% CI 99.4, 99.7%]), and with a ~ tenfold improved coefficient of determination when predicting costs (R2: 0.195-0.412 among population subgroups vs 0.022-0.050). Our best-performing model also reversed the lower sensitivity of risk prediction for Black versus White patients, a bias present in the standard cost-based model. Our results demonstrate a modeling approach to substantially improve risk prediction performance and equity for patients receiving Medicaid.
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Affiliation(s)
- Sadiq Y Patel
- Clinical Product Development, Waymark, San Francisco, CA, USA.
- School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA, 19104, USA.
| | - Aaron Baum
- Clinical Product Development, Waymark, San Francisco, CA, USA
- Icahn School of Medicine at Mt Sinai, New York, NY, USA
| | - Sanjay Basu
- Clinical Product Development, Waymark, San Francisco, CA, USA
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Center for Vulnerable Populations, San Francisco General Hospital/University of California San Francisco, San Francisco, CA, USA
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Feher A, Menashe I, Miller J, Wolf E. Personalized Letters And Emails Increased Marketplace Enrollment Among Households Eligible For Zero-Premium Plans. Health Aff (Millwood) 2023; 42:585-593. [PMID: 37011315 DOI: 10.1377/hlthaff.2022.01301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
More than one million low-income uninsured people are eligible for zero-premium cost-sharing reduction (CSR) silver plans through the Affordable Care Act (ACA) Marketplaces. However, many are not aware of these options, and Marketplaces are uncertain about what types of informational messages will increase take-up. In 2021 and 2022, before and after the introduction of zero-premium plans in Covered California, California's individual ACA Marketplace, we conducted two randomized controlled trials among low-income households that submitted an application and were found eligible for $1 per month or zero-premium coverage but were not yet enrolled. We tested the effect of personalized letters and emails that informed households that they were eligible for a $1 per month or zero-premium CSR silver plan. Across both settings, low-cost personalized outreach increased rates of ACA enrollment, CSR silver plan take-up, and $1 per month or zero-premium CSR silver plan take-up. But even with free or nearly free coverage options, absolute rates of enrollment remained low, suggesting that more resource-intensive efforts are needed to help prospective enrollees overcome nonprice barriers.
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Affiliation(s)
- Andrew Feher
- Andrew Feher , Covered California, Sacramento, California
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Pando C, Tait ME, McGuire CM, Perez-Sanz S, Baum L, Fowler EF, Gollust SE. Health Insurance Ad Messages Targeted to English- and Spanish-Speaking Populations in a Period of Limited Federal Investment in Marketplace Outreach. Med Care Res Rev 2022; 79:798-810. [PMID: 35708017 PMCID: PMC10339780 DOI: 10.1177/10775587221101295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Federal funding cuts to enrollment outreach and marketing of the Affordable Care Act (ACA) marketplace options in 2017 has raised questions about the adequacy of the information the public has received, especially among populations vulnerable to uninsurance. Using health insurance ads aired from January 1, 2018, through December 21, 2018, we conducted a content analysis focused on (a) the messaging differences by ad language (English vs. Spanish) and (b) the messaging appeals used by nonfederally sponsored health insurance ads in 2018. The results reveal that privately sponsored ads focused on benefit appeals (e.g., prescription drugs), while publicly sponsored ads emphasized financial assistance subsidies. Few ads, regardless of language, referenced the ACA explicitly and privately sponsored Spanish-language ads emphasized benefits (e.g., choice of doctor) over enrollment-relevant details. This study emphasizes that private-sponsored television marketing may not provide specific and actionable health insurance information to the public, especially for the Spanish-speaking populations.
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Affiliation(s)
- Cynthia Pando
- University of Minnesota School of Public Health, Minneapolis, USA
| | | | | | - Sarah Perez-Sanz
- University of Minnesota School of Public Health, Minneapolis, USA
| | - Laura Baum
- Wesleyan University, Middletown, CT, USA
| | | | - Sarah E. Gollust
- University of Minnesota School of Public Health, Minneapolis, USA
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Ravel K, Ahrary J, Avakian K, Feher A, Menashe I. Effect of Personalized Outreach on Medicaid to Marketplace Coverage Transitions: A Randomized Clinical Trial. JAMA HEALTH FORUM 2022; 3:e223616. [PMID: 36239955 PMCID: PMC9568803 DOI: 10.1001/jamahealthforum.2022.3616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This randomized clinical trial examines the effect of email reminders, personalized telephone outreach, and a combination of both on Affordable Care Act enrollment among households who recently lost Medicaid and became eligible for subsidized marketplace coverage in 2017 in California.
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McIntyre A. Evidence-Based Outreach Strategies for Minimizing Coverage Loss During Unwinding. JAMA HEALTH FORUM 2022; 3:e223581. [PMID: 36239957 DOI: 10.1001/jamahealthforum.2022.3581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Staiger B, Li A, Alexander D, Schnell M. Enrollment Brokers Did Not Increase Medicaid Enrollment, 2008-18. Health Aff (Millwood) 2022; 41:1333-1341. [PMID: 36067426 DOI: 10.1377/hlthaff.2022.00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Between 2008 and 2018, six states and Washington, D.C., began contracting with enrollment brokers to facilitate enrollment into Medicaid, joining the eighteen states that already had such contracts in place as of 2008. Using newly collected data covering all contracts between state Medicaid agencies and independent enrollment brokers during this period, we compared changes in Medicaid participation following the initiation of contracts with enrollment brokers with contemporaneous changes in Medicaid participation in states that never contracted with brokers. We found that contract initiation had no statistically significant effects on state-level Medicaid participation. We further found no evidence of other enrollment-related benefits, such as improved application processing times.
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Affiliation(s)
- Becky Staiger
- Becky Staiger , Stanford University, Stanford, California
| | - Anran Li
- Anran Li, Northwestern University, Evanston, Illinois
| | - Diane Alexander
- Diane Alexander, University of Pennsylvania, Philadelphia, Pennsylvania; and National Bureau of Economic Research, Cambridge, Massachusetts
| | - Molly Schnell
- Molly Schnell, Northwestern University and National Bureau of Economic Research
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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] [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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