Dan M. Shane

Will health care reform reduce disparities in insurance coverage?: Evidence from the dependent coverage mandate.

Objectives:We used data from the Medical Expenditure Panel Survey to assess the impact of the Affordable Care Act’s dependent coverage mandate on disparities in health insurance coverage rates and evaluated whether non-Hispanic blacks and Hispanics gained coverage at the same rates as non-Hispanic whites. Methods:To estimate changes in insurance rates, we employed a difference-in-difference regression approach comparing 7962 young adults aged 19–25 to 9321 adults aged 27–34. Separate regressions were estimated for non-Hispanic blacks, Hispanics, and non-Hispanic whites to understand whether the mandate had differential effects by race/ethnicity. Separate regressions by income level and race/ethnicity were also estimated. Results:Insurance rates increased by 9.3 percentage points among non-Hispanic whites, 7.2 percentage points among Hispanics, and 9.4 percentage points among non-Hispanic blacks. These changes were not significantly different from each other. Among individuals with income of <133% of the Federal Poverty Level, non-Hispanic whites experienced significantly larger gains, whereas at higher-income levels, non-Hispanic blacks experienced significantly larger gains than other racial/ethnic groups. Conclusions:The dependent coverage mandate of the Affordable Care Act increased insurance rates among all racial and ethnic groups but did not change overall disparities. Disparities may have widened among low-income populations which highlights the importance of Medicaid expansions in reducing disparities. Among higher-income populations, disparities between non-Hispanic blacks and non-Hispanic whites were reduced.

Does prescription drug coverage improve mental health? Evidence from Medicare Part D.

The introduction of the Medicare Prescription Drug program (Part D) in 2006 resulted in a significant increase in access to coverage for older adults in the U.S. Several studies have documented the impact of this program on prescription drug utilization, expenditures and medication adherence among older adults. However, few studies have evaluated the extent to which these changes have affected the health of seniors. In this study we use data from the Health and Retirement Study to identify the impact of the Medicare Part D program on mental health. Using a difference-in-difference approach, we find that the program significantly reduced depressive symptoms among older adults. We explore the mechanisms through which this effect operates and evaluate heterogeneity in impact.

Continued Gains in Health Insurance but Few Signs of Increased Utilization An Update on the ACA’s Dependent Coverage Mandate

Objectives: To evaluate the Affordable Care Act’s dependent coverage mandate impact on insurance take-up and health services use through the second full year of implementation. Data: Medical Expenditure Panel Survey from 2006 to 2012. Study Design: Difference-in-difference regressions comparing pre-/postpolicy-outcome changes between 19- to 25-year-olds and 27- to 34-year-olds. Principal Findings: Following significant increases in 2011, insurance take-up among 19- to 25-year-olds leveled off overall in 2012. However, increases in coverage for Black young adults were higher in 2012 compared to 2011. Despite increased coverage, there is little evidence of an overall effect on health services use postmandate. Evidence points to increased doctor visits and emergency department visits among Hispanics in the first year postmandate. Conclusions: The Affordable Care Act young adult mandate led to significant gains in insurance take-up, though evidence suggests that the bulk of the gains occurred in the first year after the mandate. Gains for Black young adults appear to have picked up in 2012.

Spillover Effects of the Affordable Care Act? Exploring the Impact on Young Adult Dental Insurance Coverage

OBJECTIVES To assess whether the Affordable Care Acts (ACA) dependent coverage health insurance mandate had a spillover impact on young adult dental insurance coverage and whether any observed effects varied by household income. DATA Medical Expenditure Panel Surveys from 2006 through 2011. STUDY DESIGN We employed a difference-in-difference regression approach comparing changes in insurance rates for young adults ages 19-25 years to changes in insurance rates for adults ages 27-30 years. Separate regressions were estimated by categories of household income as a percentage of the Federal Poverty Level (FPL) to understand whether the mandate had heterogeneous spillover effects. RESULTS Private dental insurance increased by 6.7 percentage points among young adults compared to a control group of 27-30-year olds. Increases were concentrated at middle-income levels (125-400 percent FPL). CONCLUSIONS The dependent coverage mandate provision of the Affordable Care Act has not only increased health insurance rates among young adults but also dental insurance coverage rates.

Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach.

PURPOSE The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state. MATERIALS AND METHODS Observational case-control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models. RESULTS A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5-1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of

Achieving regionalization through rural interhospital transfer

6897 (95% CI

The Impact of Medicare Part D on Emergency Department Visits.

5769-8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with

The Increasing Use of Cannabis Among Older Americans: A Public Health Crisis or Viable Policy Alternative?

5167 (95% CI

Rural Patients With Severe Sepsis or Septic Shock who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach.

3696-6638) in additional cost. CONCLUSIONS The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.

Medicaid Health Home Reducing Costs and Reliance on Emergency Department: Evidence From Iowa.

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.