Category Archives: Health Care

Medicaid Expansion Affects Rural And Urban Hospitals Differently

Source: Brystana G. Kaufman, Kristin L. Reiter, George H. Pink and George M. Holmes, Health Affairs, vol. 35 no. 9, September 2016
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From the abstract:
Rural hospitals differ from urban hospitals in many ways. For example, rural hospitals are more reliant on public payers and have lower operating margins. In addition, enrollment in the health insurance Marketplaces of the Affordable Care Act (ACA) has varied across rural and urban areas. This study employed a difference-in-differences approach to evaluate the average effect of Medicaid expansion in 2014 on payer mix and profitability for urban and rural hospitals, controlling for secular trends. For both types of hospitals, we found that Medicaid expansion was associated with increases in Medicaid-covered discharges. However, the increases in Medicaid revenue were greater among rural hospitals than urban hospitals, and the decrease in the proportion of costs for uncompensated care were greater among urban hospitals than rural hospitals. This preliminary analysis of the early effects of Medicaid expansion suggests that its financial impacts may be different for hospitals in urban and rural locations.

US Hospitals Are Still Using Chargemaster Markups To Maximize Revenues

Source: Ge Bai and Gerard F. Anderson, Health Affairs, vol. 35 no. 9, September 2016
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From the abstract:
Many hospital executives and economists have suggested that since Medicare adopted a hospital prospective payment system in 1985, prices on the hospital chargemaster (an exhaustive list of the prices for all hospital procedures and supplies) have become irrelevant. However, using 2013 nationally representative hospital data from Medicare, we found that a one-unit increase in the charge-to-cost ratio (chargemaster price divided by Medicare-allowable cost) was associated with $64 higher patient care revenue per adjusted discharge. Furthermore, hospitals appeared to systematically adjust their charge-to-cost ratios: The average ratio ranged between 1.8 and 28.5 across patient care departments, and for-profit hospitals were associated with a 2.30 and a 2.07 higher charge-to-cost ratio than government and nonprofit hospitals, respectively. We also found correlation between the proportion of uninsured patients, a hospital’s system affiliation, and its regional power with the charge-to-cost ratio. These findings suggest that hospitals still consider the chargemaster price to be an important way to enhance revenue. Policy makers might consider developing additional policy tools that improve markup transparency to protect patients from unexpectedly high charges for specific services.

Affordable Care Act’s Mandate Eliminating Contraceptive Cost Sharing Influenced Choices Of Women With Employer Coverage

Source: Caroline S. Carlin, Angela R. Fertig and Bryan E. Dowd, Health Affairs, vol. 35 no. 9, September 2016
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From the abstract:
Patient cost sharing for contraceptive prescriptions was eliminated for certain insurance plans as part of the Affordable Care Act. We examined the impact of this change on women’s patterns of choosing prescription contraceptive methods. Using claims data for a sample of midwestern women ages 18–46 with employer-sponsored coverage, we examined the contraceptive choices made by women in employer groups whose coverage complied with the mandate, compared to the choices of women in groups whose coverage did not comply. We found that the reduction in cost sharing was associated with a 2.3-percentage-point increase in the choice of any prescription contraceptive, relative to the 30 percent rate of choosing prescription contraceptives before the change in cost sharing. A disproportionate share of this increase came from increased selection of long-term contraception methods. Thus, the removal of cost as a barrier seems to be an important factor in contraceptive choice, and our findings about long-term methods may have implications for rates of unintended pregnancy that require further study.
Early Impact Of The Affordable Care Act On Oral Contraceptive Cost Sharing, Discontinuation, And Nonadherence
Source: Lydia E. Pace, Stacie B. Dusetzina and Nancy L. Keating, Health Affairs, vol. 35 no. 9, September 2016
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Number Of Medicaid Prescriptions Grew, Drug Spending Was Steady In Medicaid Expansion States

Source: Hefei Wen, Tyrone F. Borders and Benjamin G. Druss, Health Affairs, vol. 35 no. 9, September 2016
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From the abstract:
Expansions of eligibility for Medicaid under the Affordable Care Act may have increased the number of Medicaid drug prescriptions. However, the expansions did not drive Medicaid spending on prescription drugs overall in 2014.
Recent Growth In Medicare Advantage Enrollment Associated With Decreased Fee-For-Service Spending In Certain US Counties
Source: Garret Johnson, José F. Figueroa, Xiner Zhou, E. John Orav and Ashish K. Jha, Health Affairs, vol. 35 no. 9, September 2016
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Gaining Coverage Through Medicaid Or Private Insurance Increased Prescription Use And Lowered Out-Of-Pocket Spending
Source: Andrew W. Mulcahy, Christine Eibner and Kenneth Finegold, Health Affairs, vol. 35 no. 9, September 2016
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Public Funds Account for Over 70 Percent of Health Care Spending In California

Source: Andrea Sorensen, Narissa J. Nonzee, and Gerald F. Kominski,UCLA Center for Health Policy Research, Health Policy Brief, August 2016

From the abstract:
The authors find that personal health care expenditures are estimated to total more than $367 billion in 2016 and that approximately 71 percent of these expenditures will be paid for with public funds (i.e., taxpayer dollars). This estimated contribution of public funds to health care expenditures is much higher than estimates that include only major health insurance programs such as Medicare and Medicaid. Several additional public funding sources also contribute to health care expenditures in the state, including government spending for public employee health benefits, tax subsidies for employer-sponsored insurance and the Affordable Care Act (ACA) insurance exchange, and county health care expenditures. As health care reform continues to take effect, it will be important to monitor the public versus private contributions to state health care expenditures to ensure that funds are being distributed both efficiently and equitably.

Preliminary Data on Insurer Exits and Entrants in 2017 Affordable Care Act Marketplaces

Source: Cynthia Cox, Ashley Semanskee, Kaiser Family Foundation, August 28, 2016

The following charts provide a preliminary picture of the potential effect insurer exits and entrants may have on competition and consumer choice in the Affordable Care Act (ACA) marketplaces. This analysis was done at the request of the Wall Street Journal. Our earlier analysis found that UnitedHealth’s absence from these markets would leave many parts of the country with fewer marketplace insurers, and that the number of counties with a single insurer would likely increase substantially if there were no new entrants. Similarly, our July analysis of insurer participation in 17 states with detailed, publicly available premium and participation data found that on average there would be fewer insurers participating in 2017 in these states than there had been in 2016 or 2015.

Since the time of our earlier analyses, more details have emerged on the degree to which some insurance companies, most recently Aetna and Oscar, are planning to scale back or withdrawing their participation on the marketplaces. Meanwhile other insurers, including Cigna, have noted their intent to enter into new markets or expand their offerings in their 2017 rate filings to state regulators.

Despite these new details, much is still unknown and the majority of states’ 2017 filings are either redacted or unavailable publicly. Because only premium changes, and not new entrant premiums, are posted on’s rate review site, it is also likely that more is known at this time of market exits than is known of entrants. Complete information on insurer participation and premiums across all states does not typically become public until shortly before the beginning of the open enrollment season. It is therefore likely that the complete picture of how entrants and exits are shaping these markets in 2017 will not come into focus for two more months.

Black Workers, Unions, and Inequality

Source: Cherrie Bucknor, Center for Economic and Policy Research (CEPR), August 2016

From the summary:
This study uses the most recent Census Bureau data available to examine the trends in unionization for Black workers, focusing on unionization rates as well as the demographic composition of the Black union workforce. This paper also presents data on the impact of unionization on the wages and benefits of Black workers and how these benefits work to reduce racial wage inequality.

Unionization rates have been in decline across the board for decades. Despite this fact, Black workers are still more likely than workers of any other race or ethnicity to be unionized. In 2015, 14.2 percent of Black workers and 12.3 percent of the entire workforce were represented by unions, down from 31.7 percent and 23.3 percent, respectively, in 1983. This large decline in unionization has occurred alongside, and contributed to, an increase in overall wage inequality, as well as the widening Black-white wage gap.

This paper finds that Black union workers of today are very different from Black union workers of the past. In particular, Black union workers today are more likely to be female, older, have more years of formal education, be immigrants, and work in the public sector.

Black union workers also enjoy higher wages, and better access to health insurance and retirement benefits than their non-union peers. These benefits persist even after controlling for systematic differences between the union and non-union workforce. Specifically, Black union workers on average earn 16.4 percent higher wages than non-union Black workers. Black union workers are also 17.4 percentage points more likely than non-union Blacks to have employer-provided health insurance, and 18.3 percentage points more likely to have an employer-sponsored retirement plan.

These benefits are also large for Black workers in low-wage occupations and those with fewer years of formal education. Black union workers in low-wage occupations have wages that are 18.9 percent higher than their non-union counterparts, are 13.1 percentage points more likely to have employer-provided health insurance, and 15.4 percentage points more likely to have employer-sponsored retirement plans. Furthermore, Black union workers with less than a high school degree have a wage advantage of 19.6 percent over their non-union peers, and are 23.4 percentage points and 25.2 percentage points more likely to have health insurance and a retirement plan, respectively.

Some other highlights include:
– The percent of Black union workers who are immigrants has more than doubled since 1994: from 7.0 percent in 1994, to 15.4 percent in 2015.
– Black immigrants are more likely than native Blacks to be unionized. In 2015, Black immigrant workers had a unionization rate of 16.9 percent compared to 13.8 percent for native Blacks.
– Unionization rates for Black workers have declined across all sectors, but the decline has been especially steep for manufacturing (from 42.3 percent in 1983 to 13.3 percent in 2015).
– Black union workers on average earn $24.24 per hour, compared to $17.78 for non-union Black workers.
– 71.4 percent of Black union workers have employer-provided health insurance, compared to 47.7 percent of non-union Black workers.
– 61.6 percent of Black union members have employer-sponsored retirement plans, compared to 38.2 percent of non-union Black workers.

The Six C’s of an Effective Response to the Zika Virus

Source: Kendra Smal, Center for American Progress, August 26, 2016

….To fully protect young Americans from the effects of Zika, policymakers must expand reproductive rights for young people by addressing the six C’s: comprehensive sex education, confidentiality, contraceptive counseling, choice, community support for young parents, and congressional action….

The High Cost of Prescription Drugs in the United States: Origins and Prospects for Reform

Source: Aaron S. Kesselheim, Jerry Avorn, Ameet Sarpatwari, Journal of the American Medical Association – JAMA, Vol. 316 No. 8, August 23/30, 2016

From the abstract:
Importance:  The increasing cost of prescription drugs in the United States has become a source of concern for patients, prescribers, payers, and policy makers.

Objectives:  To review the origins and effects of high drug prices in the US market and to consider policy options that could contain the cost of prescription drugs.

Evidence:  We reviewed the peer-reviewed medical and health policy literature from January 2005 to July 2016 for articles addressing the sources of drug prices in the United States, the justifications and consequences of high prices, and possible solutions.

Findings:  Per capita prescription drug spending in the United States exceeds that in all other countries, largely driven by brand-name drug prices that have been increasing in recent years at rates far beyond the consumer price index. In 2013, per capita spending on prescription drugs was $858 compared with an average of $400 for 19 other industrialized nations. In the United States, prescription medications now comprise an estimated 17% of overall personal health care services. The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents. The availability of generic drugs after this exclusivity period is the main means of reducing prices in the United States, but access to them may be delayed by numerous business and legal strategies. The primary counterweight against excessive pricing during market exclusivity is the negotiating power of the payer, which is currently constrained by several factors, including the requirement that most government drug payment plans cover nearly all products. Another key contributor to drug spending is physician prescribing choices when comparable alternatives are available at different costs. Although prices are often justified by the high cost of drug development, there is no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.

Conclusions and Relevance:  High drug prices are the result of the approach the United States has taken to granting government-protected monopolies to drug manufacturers, combined with coverage requirements imposed on government-funded drug benefits. The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices.

The Structural Burden of Caregiving: Shared Challenges in the United States and Canada

Source: Miles G. Taylor and Amélie Quesnel-Vallée, The Gerontologist, Advance Access, First published online: August 12, 2016
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From the abstract:
In contrasting health care structures, we each served as caregivers to elderly parents where a shared and unexpected theme in our experiences was the substantial burden of negotiating and managing long-term care (LTC) services within our respective health and social care systems. In this article, we introduce and elucidate an under recognized source of caregiver burden in the United States and Canada: the structural burden of caregiving. We draw on shared and unique experiences cross-nationally, along with the literature, to illustrate that (a) today’s caregiving is increasingly characterized by interactions with formal health and social systems in negotiating and managing services, (b) these systems are hampered by discontinuous and fragmented care which increase caregiver stress, and (c) this structural burden likely exacerbates inequity for both care recipients and caregivers. In conclusion, we call for theoretical models of caregiving to highlight health and social systems as creating burden and for measurement of caregiver burden to explicitly consider the time and stress stemming from interactions with formal health and social systems. Finally, we call for future policy evaluation to incorporate structural burden as an additional outcome in considering changes to LTC provisions and funding.