• Measuring Coverage Rates in a Pandemic

      10/27/2020
      Adrianna McIntyre

    My coauthors (Matt Brault and Ben Sommers) and I published a piece in JAMA Health Forum yesterday laying out the challenges inherent to evaluating how the COVID-19 pandemic has affected health coverage. We’ve also put together a table of surveys used to study coverage—including national, nongovernmental surveys fielded by private organizations in response to the pandemic—as a general resource.

    The usual-suspect national surveys (ACS, CPS, NHIS) won’t make 2020 data available for months yet. The Census (in coordination with BLS and CDC) did the herculean task of standing up and fielding a rapid-response survey starting in April, but the first wave of the survey had a worryingly low response rate and it’s hard to assess the reliability of its estimates without a pre-pandemic baseline. Private organizations have stepped up to field fast national surveys, but those necessarily obscure important regional variation. Local surveys have sprung up in some places—SHADAC has a great resource of available surveys—but they can’t be directly compared. The pandemic itself has affected survey administration (government surveys were paused in the early spring) and response rates.

    Most worryingly, the gold-standard government surveys use coverage metrics that make it hard to understand when in the year someone lost coverage, which will hamper future research. In ordinary times, coverage rates averaged across the year may not be particularly bothersome. But when we’re talking about evaluating a pandemic-recession that has ebbed and flowed across the country, averages  fall short of meeting research needs.

    Fortunately, better data is possible:

    Currently, the CPS Annual Social and Economic Supplement public files report coverage at the time of interview and ever having had coverage in the prior year. The survey collects more granular data—not included in public files—about coverage in each month of the year prior to the interview. The ACS measures coverage at the time of interview and surveys respondents throughout the year but does not disclose the month of interview in its public data release. But a data set that provides a blended average of coverage rates from January, May, and December 2020 obscures the most critical effects of the COVID-19 pandemic. If the Census Bureau released the CPS longitudinal file and the ACS month of interview (or even quarter of interview), with appropriate confidentiality protections in place, this would immeasurably improve researchers’ ability to identify coverage changes before, during, and after the pandemic.

    There is precedent for this kind of change in public use files under extraordinary circumstances: for the 2005 ACS, the Census made flags available so that researchers could distinguish between people interviewed before and after Hurricane Katrina in the affected Gulf region. It’s possible that the Census is already considering this kind of accommodation, but we thought that this issue—and available solution—should be on the radar of the broader health services research community.

    You can read the full piece here.

    Adrianna (@onceuponA)

     
      Uncategorized
      COVID-19, insurance, uninsured
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  • JAMA Forum: Medicaid as a Safeguard for Financial Health

      11/28/2018
      Aaron Carroll

    Go read my latest piece over at the JAMA Forum:

    Home insurance doesn’t make a home less flammable. It protects homeowners against financial disaster should something happen to their home. The same holds true for auto insurance, for life insurance, and for disability insurance. And though we often talk about health insurance in terms of making people healthier, its true goal is the same as with other insurance: to safeguard the financial health of beneficiaries in the face of undesirable circumstances.

    Even in that respect, the Medicaid expansion appears to be working.

    Many articles have focused on the positive effects of Medicaid on health and well-being of recipients. A recent National Bureau of Economic Research working paper highlighted instead the effect of Michigan’s Medicaid expansion on Medicaid recipients’ financial health.

    You’re still here? I said go read it at the JAMA Forum!

    @aaronecarroll

     

     
      Health Policy
      financial health, insurance, JAMA Forum, Medicaid
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  • Healthcare Triage: Rising Pet Care Costs Might Tell Us Something about Human Health Care Costs

      02/07/2017
      Aaron Carroll

    In almost every year since the 1960s, health care spending has grown at least as fast as the overall economy, and often much faster. Health economists have long debated why.

    Strange as it may sound, how we care for our pets offers some answers. That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from a column Austin wrote for the Upshot. Links to resources and further reading can be found there.

    @aaronecarroll

     
      Health Policy
      Healthcare Triage, insurance, pets, Upshot
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  • Has the Affordable Care Act increased competition in the individual market?

      12/10/2015
      guest contributor

    Josh Fangmeier is a health policy analyst based in Ann Arbor, Michigan. He occasionally tweets at @joshfangmeier.

    A basic premise of the Affordable Care Act (ACA) is that greater competition among insurers in regional, individual (non-group) markets would provide better options and value to consumers. So, it’s worth asking, to what extent did competition change in those markets when the key ACA provisions were implemented in 2014?

    The ACA introduced several major reforms to the individual health insurance market in 2014, including launching the online marketplaces, requiring insurers to guarantee issue, and establishing sets of essential health benefits for all plans.1 What was the aggregate impact of these changes on competition?

    Using federal data, I calculated the market share of each insurer in each state’s individual market, combining enrollment on and off the health insurance marketplaces in 2013 and 2014. In 2013, the largest insurer held over half of individual market enrollment in 28 states and the District of Columbia. (See Figure 1, the data for which is here.) In Vermont and Rhode Island, the largest insurer had over 90 percent market share.

    Figure1

    In 2014, about 6.7 million people enrolled in coverage through the marketplaces, and total individual market enrollment (on and off the marketplaces) grew from 10.6 million to 15.6 million, according to the Kaiser Family Foundation. However, this growth was uneven as states like New York (141 percent) grew much more than other states like Ohio (15 percent). Depending on which insurers in each state gained new members, individual market competition either increased or decreased under the ACA.

    To calculate changes in competition, I compared the Herfindahl-Hirschman Index (HHI) of each state’s individual market in 2013 and 2014. The HHI is a standard measure of competition within an industry and is calculated from adding up the squares of each insurer’s market share. Smaller HHI values indicate more competition, while larger values indicate more market concentration. The HHI is admittedly not a perfect measure of competiveness, as it does not account for how much firms strive to meet consumer demands, but there are few accessible alternatives.

    From 2013 to 2014, individual market competition increased in 20 states. (See Figure 2, the data for which is here.) For example, in Iowa, the HHI decreased as the state’s largest insurer, Wellmark, lost market share. This is likely due to Wellmark’s decision to stay out of offering coverage on the health insurance marketplace for the first three years. In the other 30 states and the District of Columbia, individual market competition decreased. For example, in Illinois, the largest insurer, Blue Cross Blue Shield of Illinois, grew its market share from 65 to 81 percent.

    Figure2

    The increase in competition in less than half of states under the ACA is a surprising outcome, since the law lowered certain barriers to entry. For instance, it decreased marketing costs by selling plans through the marketplaces and cushioned plans against adverse selection. However, the closure of more than half of the ACA co-op plans demonstrates the challenges for new insurers to enter these markets.

    The degree to which individual market competition helps consumers is still unclear. On average consumers have five carriers to choose from in the marketplaces, and more choice of insurers in the marketplaces is associated with lower premiums. Also, four out of five enrollees are satisfied with their marketplace coverage. It may be possible that consumers are choosing more established insurers due to brand recognition, quality plan offerings, or favorable rates due to leverage with providers.

    Competition in individual markets is likely to change going forward. With this year’s proposed mergers among some of the largest national insurers, much attention has been paid to how these mergers could affect consumers and providers and how they may reduce competition across states. Whatever their source, changes in competition are worth monitoring2 as the individual markets continue to mature under the ACA reforms.

    [1] While the ACA created national standards for individual market coverage, not all state insurance markets made the same transition in 2014. Prior to ACA reforms, six states already had some form of guarantee issue requirements and another four states had designated their local Blue Cross Blue Shield carrier as the insurer of last resort.

    [2] The most common source of this information comes from insurer filings with regulators. Updated data for the 2015 calendar year will likely not be available until mid to late 2016.

     
      Health Policy
      Affordable Care Act, competition, insurance
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  • Underinsurance, ctd.

      12/04/2014
      Aaron Carroll

    I got a nice email from Charles Orenstein this morning telling me about a new ProPublica app with which you can shop for exchange plans, and see how things have changed from last year to this one. Just for the heck of it, I entered data for my family of five and took it for a spin.

    Here’s the first plan I checked, a silver plan offered by Anthem:

    Silver one

    The good news, I suppose, is that premiums have only gone up by 3.6%. That’s a reasonably small amount, when it comes to health care spending growth. The only other major change was that a co-pay for the emergency room was added after the deductible was met. So… hooray?

    But consider this. The deductible for this plan is $7000. That means that, unless you make $140,000 a year, this alone leaves you underinsured. Yes, cost-sharing subsidies will help reduce this amount for those at the lower end of the socio-economic spectrum, but not as much as you’d think. And a lot of people won’t get cost-sharing subsidies, even if they’re getting help covering their premiums.

    Let’s say a nice family of five in Indiana has a combined income of $120,000 earning them too much for subsidies. The median income, by the way, for a family of 5 in Indiana in 2013 was $67,189. So this family is doing well. This plan – a silver plan, mind you – would cost them $16,591 in premiums each year. Then, they’d have a $7000 deductible. They’d spend more than $23,500, almost 20% of their income, before insurance would start to kick in.

    Remember that we don’t consider this catastrophic care. We don’t even consider this high-deductible, or consumer driven, care. This is comprehensive coverage in the United States of America.

    @aaronecarroll

     
      Health Policy
      exchange, insurance
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  • Best in the world, my a$$! – Emergency Departments and Networks

      09/29/2014
      Aaron Carroll

    When I was a sophomore in college, I was playing an intramural baseball game against a bunch of upperclassmen. One sunny Sunday afternoon, I hit a nice shot down the third base line, and took off for first. But the first baseman might have been a bit inebriated. He was also easily twice my size. I remember him suddenly stepping into the basepath, and I remember literally bouncing off his stomach before I hit the ground.

    I also remember the sound my arm made as it broke. A number of my friends reported that they could hear the crack as well.

    I was in a great deal of pain. One of my roommates ran to get his car, and pulled it onto the field. Everyone loaded me into the back seat, and my roommate took off for the hospital.

    It turned out that I’d broken both the bones in my left forearm. The pain was so bad that when they turned my arm over to get an x-ray, I nearly passed out. The idea that I could be a good “medical shopper” at this point was laughable. I was hurt, incoherent, and going to get care wherever I could. Today, the health care system requires us to be better. It demands that we go to emergency rooms that are “in network”. People actually do this! But it turns out that even when they do, they’re still getting screwed:

    When Jennifer Hopper raced to the emergency room after her husband, Craig, took a baseball in the face, she made sure they went to a hospital in their insurance network in Texas. So when they got a $937 bill from the emergency room doctor, she called the insurer, assuming it was in error.

    But the bill was correct: UnitedHealthcare, the insurance company, had paid its customary fee of $151.02 and expected the Hoppers to pay the remaining $785.98, because the doctor at Seton Northwest Hospital in Austin did not participate in their network.

    Yep, it turns out that even if you go to a emergency room that’s “in network”, the emergency room doctor may not be. Think about that. I mean, asking people who are acutely injured or sick to have the presence of mind to be able to shop around is already insane, but then it turns out THAT IT DOESN’T EVEN MATTER.

    How common is this, you might ask?

    When emergency medicine emerged as a specialty in the 1980s, almost all E.R. doctors were hospital employees who typically did not bill separately for their services. Today, 65 percent of hospitals contract out that function. And some emergency medicine staffing groups — many serve a large number of hospitals, either nationally or locally — opt out of all insurance plans.

    That’s right, two-thirds of hospitals have out-of-network doctors working in their in-network emergency rooms. Good luck rolling the dice! And this doesn’t help:

    Dr. Jeffrey Bettinger, chairman of the reimbursement committee of the American College of Emergency Physicians, said that out-of-network emergency room doctors were an unusual phenomenon and expressed doubt that the practice was widespread. When it occurred, he added, it was typically because of insurers’ unwillingness to pay doctors a reasonable rate compared to what they pay hospitals for their services.

    The average salary of an emergency room physician was $311,000 in 2014, rising from $247,000 since 2010 — a period when many other types of doctors experienced declines in salaries, according to Merritt Hawkins, a physician staffing firm.

    Either the NYT is wrong with their “65%” figure, or else the American College of Emergency Physicians is woefully uninformed. (UPDATED: Or, maybe both are right. It’s possible that the 65% of EDs outsourcing doesn’t add up to lots of out-of-network services. The Texas data in the NYT story tends to make me doubt that. But if the ACEP has data that makes them so sure, I wish they’d share it!) And don’t think this is something people can “learn” themselves out of:

    When Dr. Michael Schwartz’s daughter went to an emergency room in the Philadelphia suburbs for a reaction to a medication in 2010, she went to an in-network hospital, Bryn Mawr. She was there for a few hours on a cardiac monitor. While most of her care was covered by his family’s insurer, Capital Blue Cross, a bill of more than $2,000 from the out-of-network E.R. physicians for cardiac monitoring was not.

    “I tried to negotiate with the physician group, but they wouldn’t budge,” said Dr. Schwartz, a pediatrician, who ended up paying $1,200, the amount his plan required for his share of out-of-network care. “It was ridiculous. I’m a physician and I understand how this works. There was no sign saying, ‘Our physicians are out-of-network.’ ”

    If a local doctor can’t figure out how this works, then the rest of you have pretty much no chance.

    Best in the world, my ass!

    @aaronecarroll

     
      Health Policy
      insurance, networks, spending
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  • AcademyHealth: Massachusetts Health Care Reform and Chronic Disease Outcomes

      07/30/2014
      Aaron Carroll

    My latest post at the AcademyHealth blog:

    One of the critical questions about health care reform asks how much good reform will do to improve the quality of people’s health. Yes, insurance is about more than outcomes. It’s also about giving people peace of mind and providing them with financial security. But it’s also about making people healthier.

    Does it do that? After the results of the Oregon Insurance Health Experiment, many debated this issue. Some of the papers claimed that providing people with Medicaid did little to improve chronic disease. Some, like Austin and I, argued that the study wasn’t really powered to answer these questions. But that doesn’t mean those questions shouldn’t, or can’t, be answered.

    A recent paper in HSR adds to our fund of knowledge.

    Go read about it!

    @aaronecarroll

     
      Health Policy
      AcademyHealth, chronic disease, insurance, Massachusetts, quality
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  • It’s getting hard to ignore insurance numbers (UPDATED)

      06/24/2014
      Aaron Carroll

    Gallup:

    Five percent of Americans report being newly insured in 2014. More than half of that group, or 2.8% of the total U.S. population, say they got their new insurance through the health exchanges that were open through mid-April.

    Given the population of the United States, this means that more than 15 million about 10-11 million American adults are newly insured this year. Almost 9 million of them received private insurance through the exchanges. There’s more (emphasis mine):

    The age distribution of those who report newly obtaining health insurance this year through the exchanges is generally similar to what Gallup found in the preliminary report. The newly insured using exchanges are mostly under age 65, as would be expected, given that most Americans 65 and older are covered by Medicare. Thus, the representation of newly insured Americans is higher across all three age groups younger than 65 than is true for the general population. More specifically, newly insured Americans using the exchanges in the 18 to 29 age category are eight percentage points more prevalent than their percentage in the overall adult population, while representation of those 30 to 49 and 50 to 64 are five and four points higher, respectively.

    This means that the fears that the young would refrain from buying insurance, thereby fracturing the risk pools, don’t seem to be coming to pass either.

    The ACA ain’t perfect, and there’s always room for improvement, but this is how things were supposed to work. They’re also the opposite of what many opponents said would happen. I’m curious to see if and how data points like these change their rhetoric.

    @aaronecarroll

    UPDATE: It has been pointed out to me that the Gallup poll only covers adults, so the 5% represents about 10-11 million people.

     
      Health Policy
      ACA, Gallup, insurance, uninsured
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  • Stand Up! – June 4, 2014

      06/05/2014
      Aaron Carroll

    I am a frequent guest on Stand Up! with Pete Dominick, which airs on Sirius/XM radio, channel 104 from 6-9AM Eastern. It immediately replays on the channel, so those on the West Coast can listen at the same times.

    Today we talked about how doctors refer patients, the ACA, insurance, and more

    You can play the audio right here, after the jump…

    @aaronecarroll

    Read the rest of this entry »

     
      Health Policy
      ACA, insurance, Stand Up!
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  • The legality of the ACA delays

      04/03/2014
      Nicholas Bagley

    I have a short piece out at the New England Journal of Medicine titled The Legality of Delaying Key Elements of the Affordable Care Act. The piece offers what I hope is a clear, concise explanation for why, in my view, several of the ACA delays are legally questionable. (I’ve explored some of the ideas here at TIE.) The piece also describes why even supporters of the ACA—and I am emphatically a supporter—should worry about the delays.

    At the same time, the Journal has published a competing account from Tim Jost and Simon Lazarus. In their view, the delays are routine and sensible exercises of executive discretion with a sound constitutional pedigree. I don’t agree with everything they say, but I’m pleased to see the competing perspective so ably represented.

    @nicholas_bagley

     
      Health Policy, Law
      Affordable Care Act, implementation, insurance
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