Dataset Information

The Affordable Care Act and Expanded Insurance Eligibility Among Nonelderly Adult Cancer Survivors.

ABSTRACT: Cancer survivors may face barriers to accessing health insurance and experience financial hardship because of medical expenditures. We examined potential improvements in access to insurance for cancer survivors through adult Medicaid expansions and premium tax credits in the new insurance marketplaces under the Affordable Care Act (ACA).Eligibility for Medicaid and premium tax credits was simulated for cancer survivors age 18 to 64 years in the 2008 to 2010 Medical Expenditure Panel Survey using a detailed deterministic model. Financial hardship was determined as: 1) delays or unmet need for medical, prescription, or dental care because of cost or insurance issues and/or 2) family out-of-pocket medical spending that was 20% or more of gross income. Descriptive analyses were stratified by whether the state of residence chose to expand Medicaid by January 2015. All statistical tests were two-sided.Overall, 14.7% of 9.44 million cancer survivors were uninsured, with 18% reporting financial hardship. Under the ACA, 19% overall, 30% of the uninsured, and 39% of those reporting financial hardship would be Medicaid eligible. An additional 10% would be eligible for premium tax credits, with the remainder able to participate in the Marketplace without tax credits. However, 21% of uninsured cancer survivors in states not expanding Medicaid would be ineligible for assistance with coverage.Under the ACA, many of the uninsured and a larger proportion of survivors facing financial hardship will be eligible for Medicaid or premium tax credits in the Marketplaces. ACA implementation will dramatically enhance insurance availability and is likely to reduce financial hardship for vulnerable cancer survivors.

SUBMITTER: Davidoff AJ

PROVIDER: S-EPMC4651107 | biostudies-other | 2015 Sep

REPOSITORIES: biostudies-other

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The Affordable Care Act and Expanded Insurance Eligibility Among Nonelderly Adult Cancer Survivors.

Davidoff Amy J AJ Hill Steven C SC Bernard Didem D Yabroff K Robin KR

Journal of the National Cancer Institute 20150701 9

<h4>Background</h4>Cancer survivors may face barriers to accessing health insurance and experience financial hardship because of medical expenditures. We examined potential improvements in access to insurance for cancer survivors through adult Medicaid expansions and premium tax credits in the new insurance marketplaces under the Affordable Care Act (ACA).<h4>Methods</h4>Eligibility for Medicaid and premium tax credits was simulated for cancer survivors age 18 to 64 years in the 2008 to 2010 Med ...[more]

PMID: 26134034

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Project description:BackgroundLittle is known about changes in socioeconomic disparities in noninsurance and care unaffordability among nonelderly cancer survivors following the Affordable Care Act (ACA).MethodsCancer survivors aged 18-64 years nationwide were identified from the Behavioral Risk Factor Surveillance System. Trend and difference-in-differences analyses were conducted to examine changes in percent uninsured and percent reporting care unaffordability pre-(2011 to 2013) and post-(2014 to 2017) ACA Medicaid expansion, by sociodemographic factors.ResultsA total of 118 631 cancer survivors were identified from Medicaid expansion (n = 72 124) and nonexpansion (n = 46 507) states. Following the ACA, percent uninsured and percent reporting care unaffordability decreased nationwide. Medicaid expansion was associated with a 1.8 (95% confidence interval [CI] = 0.1 to 3.5) percentage points (ppt) net decrease in noninsurance and a 2.9 (95% CI = 0.7 to 5.1) ppt net decrease in care unaffordability. In stratified analyses by sociodemographic factors, substantial decreases were observed in female survivors, those with low or medium household incomes, the unemployed, and survivors with multiple comorbidities. However, we observed slightly increased percentages in reporting noninsurance (ppt = 1.7; 95% CI = -1.2 to 4.5) and care unaffordability (ppt = 3.1, 95% CI = -0.4 to 6.5) in nonexpansion states between 2016 and 2017, translating to 67 163 and 124 160 survivors, respectively.ConclusionWe observed reductions in disparities by sociodemographic factors in noninsurance and care unaffordability among nonelderly cancer survivors following the ACA, with largest decreases in women, those with low or medium income, multiple comorbid conditions, the unemployed, and those residing in Medicaid expansion states. However, the uptick of 82 750 uninsured survivors in 2017, mainly from nonexpansion states, is concerning. Ongoing monitoring of the effects of the ACA is warranted, especially in evaluating health outcomes.

Project description:ImportanceYoung adults historically have had the highest uninsured rates among all age groups. In 2014, in addition to Medicaid expansion for adults with low income (≤133% of the federal poverty level [FPL]) through the Patient Protection and Affordable Care Act, Massachusetts also extended eligibility for children (≤150% FPL) to beneficiaries aged 19 to 20 years.ObjectiveTo examine changes in insurance coverage continuity for Medicaid enrollees who turned age 19 years before and after eligibility policy changes.Design setting and participantsThis cohort study used data from the Massachusetts All-Payer Claims Database (2012 to 2016) to compare coverage for Medicaid beneficiaries turning age 19 years before and after Medicaid expansion. Monthly coverage was examined for each cohort for 3 years as beneficiaries aged from 18 and 19 years to 19 and 20 years to 20 and 21 years. Analyses were performed between November 1, 2020, and May 12, 2022.Main outcomes and measuresIn each year, the likelihood of being uninsured or having Medicaid, employer-sponsored insurance, or individual commercial coverage for 3 or more months was examined along with the likelihood of having continuous Medicaid enrollment for 12 or more and 24 or more months. Multivariable linear probability models were used to compare the likelihood of these outcomes for those in the postexpansion vs preexpansion cohorts, adjusting for sex, comorbidity levels, neighborhood socioeconomic status, and neighborhood race and ethnicity.ResultsA total of 41 247 young adults turning age 18 to 19 years in the baseline year (20 876 [50.6%] men) were included in the study, with 20 777 in the preexpansion cohort and 20 470 in the postexpansion cohort. Enrollees who turned age 19 years after vs before the Medicaid eligibility expansion were less likely to have 3 or more uninsured months at ages 18 to 19 years (4.4% [n = 891] vs 22.9% [n = 4750]; adjusted difference, -18.4 [95% CI, -19.0 to -17.7] percentage points) and 19 to 20 years (13.2% [n = 2702] vs 35.8% [n = 7447]; adjusted difference, -22.4 [95% CI, -23.2 to -21.6] percentage points) and more likely to have continuous insurance coverage for 12 or more months (94.1% [n = 19 272] vs 63.7% [n = 13 234]; adjusted difference, 30.5 [95% CI, 29.7-31.2] percentage points) or 24 or more months (77.5% [n = 15 868] vs 44.4% [n = 9221]; adjusted difference, 33.0 [95% CI, 32.1-33.9] percentage points). Differences in the likelihood of having 3 or more uninsured months diminished at ages 20 to 21 years, when both groups had access to Medicaid (ie, in calendar years 2014 for the preexpansion cohort and 2016 for the postexpansion cohort).Conclusions and relevanceIn this cohort study of young adults in Massachusetts, the combination of expanding Medicaid to lower-income adults and increasing the age threshold for child Medicaid eligibility was associated with reduced likelihood of becoming uninsured among Medicaid enrollees entering adulthood.

Project description:BACKGROUND:Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect. METHODS:We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population. RESULTS:There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains. CONCLUSION:Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities. LEVEL OF EVIDENCE:Economic analysis, level II.

Project description:ImportanceAmong adults with chronic disease, survivors of stroke have high out-of-pocket financial burdens. The US government enacted the Affordable Care Act (ACA) in 2010 and implemented the law in 2014 to provide more low-income adults with health insurance coverage.ObjectiveTo assess whether ACA implementation is associated with cost-related nonadherence (CRN) to medication among adult survivors of stroke.Design, setting, and participantsThis study analyzed data from the 2000 to 2016 National Health Interview Survey, an in-person household survey of the noninstitutionalized US population conducted annually by the National Center for Health Statistics. Conducted at the University of Michigan Medical School, Ann Arbor, from July 24, 2017, to February 28, 2018, the study had a sample of 13 930 survivors of stroke. Analyses were stratified by age (45-64 years vs ≥65 years). Time was treated as a continuous variable and as a categorical variable across 4 periods (2000-2005, historical control; 2006-2010, economic recession and peak unemployment; 2011-2013, before ACA implementation; and 2014-2016, after ACA implementation). Percentages are weighted to reflect US population estimates.Main outcomes and measuresThe primary outcome was the self-report of CRN, defined as the inability to afford prescribed medications within the past 12 months.ResultsAmong the 13 930 total survivors of stroke, 38.1% were aged 45 to 64 years (50.5% were female and 49.5% were male, with a mean [SE] age of 56.0 [0.10] years), and 61.9% were aged 65 years or older (54.9% were female and 45.1% were male, with a mean [SE] age of 76.2 [0.09] years). From 2011 to 2013 through 2014 to 2016, Medicaid increased (from 24.0% [95% CI, 21.0%-27.2%] in 2011-2013 to 30.8% [95% CI, 27.3%-34.6%] in 2014-2016; P < .001) and uninsurance decreased (from 13.7% [95% CI, 11.3%-16.4%] to 6.8% [95% CI, 5.3%-8.8%]; P < .001) among survivors of stroke aged 45 to 64 years. Among survivors aged 45 to 64 years, CRN increased over time before ACA implementation (from 18.6% [95% CI, 16.5%-20.9%] in 2000-2005, to 22.6% [95% CI, 19.7%-25.9%] in 2006-2010, to 23.8% [95% CI, 20.7%-27.3%] in 2011-2013) and decreased after ACA implementation to 18.1% (95% CI, 15.4%-21.3%; P = .01) in 2014 to 2016. The period after ACA implementation was associated with lower odds of CRN after adjustment for sociodemographics, year, and clinical factors (odds ratio [OR], 0.63; 95% CI, 0.47-0.85). The difference was attenuated after further adjustment for health insurance coverage (OR, 0.76; 95% CI, 0.56-1.03).Conclusions and relevanceAfter the ACA implementation, health insurance coverage increased and CRN decreased among adult survivors of stroke, suggesting that further expansion of Medicaid coverage is likely to be advantageous for survivors.

Project description:ImportanceDental coverage for adults is a state option in Medicaid, and despite significant gains in coverage after the Medicaid expansion under the Affordable Care Act (ACA), dental outcomes among adults in expansion states remain unexplored.ObjectiveTo explore the association of state coverage of dental benefits through Medicaid expansion with clinical dental outcomes.Design, setting, and participantsThis cross-sectional study analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2018. Included participants were low-income adults aged 19 to 64 years with income up to 138% of the federal poverty level. The study used a difference-in-differences analysis to compare changes from before to after ACA expansion in expansion states vs in control states. Changes were examined in the full sample and separately in states that did and did not provide Medicaid adult dental benefits. We defined a state as providing Medicaid adult dental benefits if it covered services beyond emergency dental benefits in 2014. Data were analyzed from November 2020 to March 2021.ExposuresMedicaid expansion under the ACA.Main outcomes and measuresRates of health coverage, having a dental visit, affordability of dental care in the past year, poor oral health, and teeth flossing were obtained from self-reported data. Mean number of missing teeth and prevalence of untreated decayed teeth, filled teeth, and functional dentition were obtained from clinical examination data.ResultsAmong 7637 low-income adults, the mean (SD) age was 37.8 (13.4) years and 4153 (weighted percentage, 54.5 %) were women. At baseline, 1732 low-income adults in nonexpansion states compared with 2520 low-income adults in expansion states were more likely, as shown by weighted percentage, to be Black (473 individuals [21.0%] vs 508 individuals [15.1%]) and US born (1281 individuals [76.7%] vs 1613 individuals [69.6%]). In the full sample, Medicaid expansion, compared with nonexpansion, was associated with an increased rate of seeing a dentist in the prior year (12.4 percentage points; 95% CI 4.6 to 20.2 percentage points; P = .003). In expansion states that provided dental benefits, compared with nonexpansion states that provided dental benefits, the expansion was associated with increases in rates of Medicaid coverage (8.2 percentage points; 95%CI 0.5 to 15.8 percentage points; P = .04) and having seen a dentist in the previous year (11.4 percentage points, 95% CI, 3.7 to 19.1 percentage points; P = .006) and decreases in the uninsured rate (-12.6 percentage points, 95% CI -18.9 to -6.4 percentage points; P < .001) and prevalence of untreated decayed teeth (-16.8 percentage points; 95% CI, -25.5 to -8.0 percentage points; P = .001). In states without Medicaid dental benefits, the expansion was associated with an increase in the mean number of missing teeth (1.3 teeth; 95% CI 0.1 to 2.5 percentage points; P = .04) and a decrease in the prevalence of functional dentition (-8.7 percentage points; 95% CI, -14.1 to -3.3 percentage points; P = .003) compared with nonexpansion states.Conclusions and relevanceThis study found that the combination of Medicaid expansion and coverage of Medicaid dental benefits was associated with improved oral health among low-income adults.

Dataset Information

The Affordable Care Act and Expanded Insurance Eligibility Among Nonelderly Adult Cancer Survivors.

Publications

The Affordable Care Act and Expanded Insurance Eligibility Among Nonelderly Adult Cancer Survivors.

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