Category Archives: Health Care

Medicaid as an Investment in Children: What is the Long-Term Impact on Tax Receipts?

Source: David W. Brown, Amanda E. Kowalski, Ithai Z. Lurie, National Bureau of Economic Research (NBER), NBER Working Paper No. 20835, January 2015
(subscription required)

From the abstract:
We examine the long-term impact of expansions to Medicaid and the State Children’s Health Insurance Program that occurred in the 1980’s and 1990’s. With administrative data from the IRS, we calculate longitudinal health insurance eligibility from birth to age 18 for children in cohorts affected by these expansions, and we observe their longitudinal outcomes as adults. Using a simulated instrument that relies on variation in eligibility by cohort and state, we find that children whose eligibility increased paid more in cumulative taxes by age 28. These children collected less in EITC payments, and the women had higher cumulative wages by age 28. Incorporating additional data from the Medicaid Statistical Information System (MSIS), we find that the government spent $872 in 2011 dollars for each additional year of Medicaid eligibility induced by the expansions. Putting this together with the estimated increase in tax payments discounted at a 3% rate, assuming that tax impacts are persistent in percentage terms, the government will recoup 56 cents of each dollar spent on childhood Medicaid by the time these children reach age 60. This return on investment does not take into account other benefits that accrue directly to the children, including estimated decreases in mortality and increases in college attendance. Moreover, using the MSIS data, we find that each additional year of Medicaid eligibility from birth to age 18 results in approximately 0.58 additional years of Medicaid receipt. Therefore, if we scale our results by the ratio of beneficiaries to eligibles, then all of our results are almost twice as large.

An Early Look At Changes In Employer-Sponsored Insurance Under The Affordable Care Act

Source: Fredric Blavin, Adele Shartzer, Sharon K. Long and John Holahan, Health Affairs, Vol. 34 no. 1, January 2015
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From the abstract:
Critics frequently characterize the Affordable Care Act (ACA) as a threat to the survival of employer-sponsored insurance. The Medicaid expansion and Marketplace subsidies could adversely affect employers’ incentives to offer health insurance and workers’ incentives to take up such offers. This article takes advantage of timely data from the Health Reform Monitoring Survey for June 2013 through September 2014 to examine, from the perspective of workers, early changes in offer, take-up, and coverage rates for employer-sponsored insurance under the ACA. We found no evidence that any of these rates have declined under the ACA. They have, in fact, remained constant: around 82 percent, 86 percent, and 71 percent, respectively, for all workers and around 63 percent, 71 percent, and 45 percent, respectively, for low-income workers. To date, the ACA has had no effect on employer coverage. Economic incentives for workers to obtain coverage from employers remain strong.

Pay-For-Performance Schemes That Use Patient And Provider Categories Would Reduce Payment Disparities

Source: Cheryl L. Damberg, Marc N. Elliott and Brett A. Ewing, Health Affairs, Vol. 34 no. 1, January 2015
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From the abstract:
Providers that care for disproportionate numbers of disadvantaged patients tend to perform less well than other providers on quality measures commonly used in pay-for-performance programs. This can lead to the undesired effect of redistributing resources away from providers that most need them to improve care. We present a new pay-for-performance scheme that retains the motivational aspects of standard incentive designs while avoiding undesired effects. We tested an alternative incentive payment approach that started with a standard incentive payment allocation but then “post-adjusted” provider payments using predefined patient or provider characteristics. We evaluated whether such an approach would mitigate the negative effects of redistributions of payments across provider organizations in California with disparate patient populations. The post-adjustment approach nearly doubled payments to disadvantaged provider organizations and greatly reduced payment differentials across provider organizations according to patients’ income, race/ethnicity, and region. The post-adjustment of payments could be a useful supplement to paying for improvement, aligning the goals of disparity reduction and quality improvement.

Out-Of-Pocket Health Care Expenditures, By Insurance Status, 2007–10

Source: Mary K. Catlin, John A. Poisal and Cathy A. Cowan, Health Affairs, Vol. 34 no. 1, January 2015
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From the abstract:
Out-of-pocket health care spending in the United States totaled $306.2 billion in 2010 and represented 11.8 percent of total national health expenditures, according to the Centers for Medicare and Medicaid Services’ National Health Expenditure Accounts. Spending by people with employer-sponsored health insurance and those covered by Medicare accounted for over 80 percent of total out-of-pocket spending. People without comprehensive medical coverage accounted for less than 8 percent of all out-of-pocket expenditures in 2010. Between 2007 and 2010 per person out-of-pocket spending grew most rapidly for people primarily covered by employer-sponsored insurance and declined for people primarily covered by Medicare and those without coverage.

Community Health Centers Employ Diverse Staffing Patterns, Which Can Provide Productivity Lessons For Medical Practices

Source: Leighton Ku, Bianca K. Frogner, Erika Steinmetz and Patricia Pittman, Health Affairs, Vol. 34 no. 1, January 2015
(subscription required)

From the abstract:
Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

State-Based Marketplaces Using ‘Clearinghouse’ Plan Management Models Are Associated With Lower Premiums

Source: Kelly Krinn, Pinar Karaca-Mandic, and Lynn A. Blewett, Health Affairs, Vol. 34 no. 1, January 2015
(subscription required)

From the abstract:
The state-based and federally facilitated health insurance Marketplaces, or exchanges, enrolled more than eight million people during the first open enrollment period, which ended March 31, 2014. There is significant variation in how states have designed and implemented their Marketplaces. We examined how premiums varied with states’ involvement in the Marketplaces through governance, plan management authority, and strategy during the first year that the exchanges have been open. State-based Marketplaces using “clearinghouse” plan management models had significantly lower adjusted average premiums for all plans within each metal level compared to state-based Marketplaces using “active purchaser” models and the federally facilitated and partnership Marketplaces. Clearinghouse management models are those in which all health plans that meet published criteria are accepted. Active purchaser models are those in which states negotiate premiums, provider networks, number of plans, and benefits. Our baseline estimates provide valuable benchmarks for evaluating future performance of states’ involvement in governance, plan management, and regulatory authority of the insurance Marketplaces.

Views on the Value of Voluntary Workplace Benefits: Findings from the 2014 Health and Voluntary Workplace Benefits Survey

Source: Paul Fronstin, Ruth Helman, Employee Benefit Research Institute (EBRI), EBRI Notes, Vol. 35 No. 11, November 2014

From the abstract:
The Employee Benefit Research Institute (EBRI) has been conducting “value of benefits” surveys for 20 years to determine the relative importance of different benefits to workers and to assess the role played by benefits in job choice and job change over time. The surveys show consistency in the value of some benefits and substantial change on others. This paper examines public opinion surrounding voluntary workplace benefits. Data come from the 2014 EBRI/Greenwald & Associates Health and Voluntary Workplace Benefits Survey (WBS). Among other topics, the survey examines a broad spectrum of workplace benefits issues, with a particular focus on voluntary workplace benefits. Workers continue to rank health insurance as the first- or second-most important benefit provided by employers. Between 1999 and 2014, the percentage of workers ranking health insurance as the first- or second-most important benefit varied between 74 percent and 82 percent. While the ranking of a retirement savings plan fell from 2001 to 2014, this may be due to the introduction of additional benefits in the survey, such as paid time off. Three-quarters of workers state that the benefits package an employer offers prospective workers is extremely (32 percent) or very (44 percent) important in their decision to accept or reject a job. Nevertheless, 34 percent are only somewhat satisfied with the benefits offered by their current employer, and 22 percent are not satisfied. Eighty-six percent of workers report that employment-based health insurance is extremely or very important, far more than for any other workplace benefit. Workers identify lower cost (compared with purchasing benefits on their own) and choice as strong advantages of voluntary benefits. However, they are split with respect to their comfort in having their employer choose their benefits provider, and think the possibility that they may have to pay the full cost of any voluntary benefits is a strong or moderate disadvantage.

The PDF for the above title, published in the November 2014 issue of EBRI Notes, also contains the fulltext of another November 2014 EBRI Notes article abstracted on SSRN: “The Gap Between Expected and Actual Retirement: Evidence From Longitudinal Data.”

Outbreaks: Protecting Americans from Infectious Diseases

Source: Jeffrey Levi, Laura M. Segal, Dara Alpert Lieberman, Kendra May, Rebecca St. Laurent, Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), December 2014

From the summary:
The Outbreaks: Protecting Americans from Infectious Diseases report finds that the Ebola outbreak exposes serious underlying gaps in the nation’s ability to manage severe infectious disease threats.
Half of states and Washington, D.C. scored five or lower out of 10 key indicators related to preventing, detecting, diagnosing and responding to outbreaks. Maryland, Massachusetts, Tennessee, Vermont and Virginia tied for the top score – achieving eight out of 10 indicators. Arkansas has the lowest score at two out of 10.

New Evidence on the Risk of Requiring Long-Term Care

Source: Leora Friedberg, Wenliang Hou, Wei Sun, Anthony Webb and Zhenyu Li, Center for Retirement Research at Boston College, WP#2014-12, November 2014

From the abstract:
Long-term care is one of the major expenses faced by many older Americans. Yet, we have only limited information about the risk of needing long-term care and the expected duration of care. The expectations of needing to receive home health care, live in an assisted living facility or live in a nursing home are essential inputs into models of optimal post-retirement saving and long-term care insurance purchase. Previous research has used the Robinson (1996) transition matrix, based on National Long Term Care Survey (NLTCS) data for 1982-89. The Robinson model predicts that men and women aged 65 have a 27 and 44 percent chance, respectively, of ever needing nursing home care. Recent evidence suggests that those earlier estimates may be extremely misleading in important dimensions. Using Health and Retirement Study (HRS) data from 1992-2010, Hurd, Michaud, and Rohwedder (2013) estimate that men and women aged 50 have a 50 and 65 percent chance, respectively, of ever needing care. But, they also estimate shorter average durations of care, resulting, as we show, from a greater chance of returning to the community, conditional on admission. If nursing home care is a high-probability but relatively low-cost occurrence, models that treat it as a lower-probability, high-cost occurrence may overstate the value of insurance.

We update and modify the Robinson model using more recent data from both the NLTCS and the HRS. We show that the low lifetime utilization rates and high conditional mean durations of stay in the Robinson model are artifacts of specific features of the statistical model that was fitted to the data. We also show that impairment and most use of care by age has declined and that the 2004 NLTCS and the 1996-2010 HRS yield similar cross-sectional patterns of care use. We revise and update the care transition model, and we show that use of the new transition matrix substantially reduces simulated values of willingness-to-pay in an optimal long-term care insurance model.
Related Issue in Brief:
“Long-Term Care: How Big a Risk?”

Comments on the HHS’ Flawed Post-Hobby Lobby Rules

Source: Lyman Johnson, David Millon, Stephen M. Bainbridge, Ronald J. Colombo, Brett McDonnell, Alan J. Meese, Nathan B. Oman, Hofstra Univiversity Legal Studies Research Paper No. 2014-23, October 20, 2014

From the abstract:
In late August 2014, after suffering a defeat in the Supreme Court Hobby Lobby decision when the Court held that business corporations are “persons” that can “exercise religion,” the Department of Health and Human Services (“HHS”) proposed new rules defining “eligible organizations.” Purportedly designed to accommodate the Hobby Lobby ruling, the proposed rules do not comport with the reasoning of that important decision and they unjustifiably seek to permit only a small group of business corporations to be exempt from providing contraceptive coverage on religious grounds. This comment letter to the HHS about its proposed rules makes several theoretical and practical points about the Hobby Lobby holding and how the proposed rules fail to reflect the Court’s reasoning. The letter also addresses other approaches to avoid in the rulemaking process and argues for rules that, unlike what the HHS has proposed, align with the Supreme Court’s reasoning while being consonant with generally applicable precepts of state law and principles of federalism.