ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study.

The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.

Evidence of Racial and Geographic Disparities in the Use of Medicare Observation Stays and Subsequent Patient Outcomes Relative to Short-Stay Hospitalizations.

PURPOSE: To examine racial and geographic disparities in the use of-and outcomes associated with-Medicare observation stays versus short-stay hospitalizations. METHODS: We used 2007-2010 fee-for-service Medicare claims, including 3,555,994 observation and short-stay hospitalizations for individuals over age 65. We estimated linear probability models with hospital fixed effects to identify within-facility disparities in observation stay use, and estimated in-hospital mortality, and 30- and 90-day post-discharge mortality, return ED visits, and hospital readmissions as a function of placement in observation using linear probability models, propensity-score matching, and interaction terms. RESULTS: We identified racial and geographic disparities in the likelihood of observation stay use within hospitals (blacks 3.9 percentage points more likely than whites, rural 5.4 percentage points less likely than urban). Observation is associated with an increased likelihood of returning to the ED within 30 or 90-days, and a decreased likelihood of readmission or mortality, but there are racial and geographic disparities in these outcomes. CONCLUSION: While observation generally results in improved outcomes, disparities in these outcomes and the use of observation stays within hospitals are concerning, and may be driven by clinical and non-clinical factors.

Costs of a Staff Communication Intervention to Reduce Dementia Behaviors in Nursing Home Care.

CONTEXT: Persons with Alzheimer's disease and other dementias experience behavioral symptoms that frequently result in nursing home (NH) placement. Managing behavioral symptoms in the NH increases staff time required to complete care, and adds to staff stress and turnover, with estimated cost increases of 30%. The Changing Talk to Reduce Resistivenes to Dementia Care (CHAT) study found that an intervention that improved staff communication by reducing elderspeak led to reduced behavioral symptoms of dementia or resistiveness to care (RTC). OBJECTIVE: This analysis evaluates the cost-effectiveness of the CHAT intervention to reduce elderspeak communication by staff and RTC behaviors of NH residents with dementia. DESIGN: Costs to provide the intervention were determined in eleven NHs that participated in the CHAT study during 2011-2013 using process-based costing. Each NH provided data on staff wages for the quarter before and for two quarters after the CHAT intervention. An incremental cost-effectiveness analysis was completed. ANALYSIS: An average cost per participant was calculated based on the number and type of staff attending the CHAT training, plus materials and interventionist time. Regression estimates from the parent study then were applied to determine costs per unit reduction in staff elderspeak communication and resident RTC. RESULTS: A one percentage point reduction in elderspeak costs $6.75 per staff member with average baseline elderspeak usage. Assuming that each staff cares for 2 residents with RTC, a one percentage point reduction in RTC costs $4.31 per resident using average baseline RTC. CONCLUSIONS: Costs to reduce elderspeak and RTC depend on baseline levels of elderspeak and RTC, as well as the number of staff participating in CHAT training and numbers of residents with dementia-related behaviors. Overall, the 3-session CHAT training program is a cost-effective intervention for reducing RTC behaviors in dementia care.

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

Cannabis use among older Americans is increasing. Although much of this growth has been attributed to the entry of a more tolerant baby boom cohort into older age, recent evidence suggests the pathways to cannabis are more complex. Some older persons have responded to changing social and legal environments and are increasingly likely to take cannabis recreationally. Other older persons are experiencing age-related health care needs, and some take cannabis for symptom management, as recommended by a medical doctor. Whether these pathways to recreational and medical cannabis are separate or somewhat tangled remains largely unknown. There have been few studies examining cannabis use among the growing population of Americans aged 65 and older. In this essay, we illuminate what is known about the intersection between cannabis and the aging American population. We review trends concerning cannabis use and apply the age-period-cohort paradigm to explicate varied pathways and outcomes. Then, after considering the public health problems posed by those who misuse or abuse cannabis, we turn our attention to how cannabis may be a viable policy alternative in terms of supporting the health and well-being of a substantial number of aging Americans. On the one hand, cannabis may be an effective substitute for prescription opioids and other misused medications; on the other hand, cannabis has emerged as an alternative for the undertreatment of pain at the end of life. As intriguing as these alternatives may be, policy makers must first address the need for empirically driven, representative research to advance the discourse.

The Impact of Medicare Part D on Emergency Department Visits.

The Medicare Part D program introduced prescription drug coverage for seniors in 2006. We examine the impact of this program on the use of emergency department (ED) care. Using a difference-in-differences model, we find declines in the number of ED visits for non-emergency care but not for emergency care, suggesting that Part D may have led to better management of health and reduced unnecessary use of EDs. Copyright © 2016 John Wiley & Sons, Ltd.

The Role of Medical Expenditure Risk in Portfolio Allocation Decisions.

Economic theory suggests that medical spending risk affects the extent to which households are willing to accept financial risk, and consequently their investment portfolios. In this study, we focus on the elderly for whom medical spending represents a substantial risk. We exploit the exogenous reduction in prescription drug spending risk because of the introduction of Medicare Part D in the U.S. in 2006 to identify the causal effect of medical spending risk on portfolio choice. Consistent with theory, we find that Medicare-eligible persons increased risky investment after the introduction of prescription drug coverage, relative to a younger, ineligible cohort. Copyright © 2016 John Wiley & Sons, Ltd.

Prescription drug coverage and chronic pain.

Chronic pain is one of the most common chronic conditions affecting more than 50 % of older adults. While pain management can be quite complex, prescription drugs are the most commonly used treatment modality. In this study, I examine whether increased access to prescription drugs due to the introduction of the Medicare Part D program in 2006 led to better management of pain among the elderly. While prior work has identified increases in the utilization of analgesics due to the introduction of Medicare Part D, the extent to which this increase in drug use actually improved the well-being of older adults is not known. Using data from the Health and Retirement Study, I employ a difference-in-differences strategy that compares pre versus post 2006 changes in pain related outcomes between Medicare eligible persons and a younger ineligible group. I find that Medicare Part D significantly reduced pain related activity limitations among a sample of older adults who report being troubled by pain.

Outcomes associated with observation versus short-stay admission among chest pain patients in the Veterans Health Administration.

BACKGROUND: To determine the extent to which 30- and 90-day hospital readmission and mortality rates differ as a function of whether a chest pain patient is placed in observation status or admitted to the hospital for a short-stay (<48 h). METHODS: Using 114,043 observation stays and short-stay admissions for chest pain at Veterans Health Administration hospitals between 2005 and 2013, we estimated event-level logistic regression models using a generalized estimating equation framework to predict 30 and 90-day readmissions and mortality as a function of whether the patient had an observation stay or a short-stay admission. We also adjusted for a variety of patient characteristics and unobserved time-invariant hospital factors. RESULTS: Relative to the short-stay inpatient group, veterans with chest pain who were placed in observation status were significantly more likely to be female (7.0 % vs. 6.4 %, White (76.6 % vs. 71.0 %, and from a rural area (28.3 % vs. 20.2 %). There were no other meaningful differences between the groups. Veterans with chest pain who were placed in observation status had 25 % lower odds of dying within 30 days (95 % confidence interval [CI]: 3 % - 43 %) and 12 % lower odds of a 30-day readmission (95 % CI: 6 % - 17 %) compared to those admitted as short-stay inpatients. Neither 90-day outcome was significantly associated with placement in observation status. Patient demographics were also important predictors of mortality and readmissions. CONCLUSIONS: There are clinically observable differences in outcomes between patients admitted to observation and those admitted as short-stay inpatients. We find no evidence that the increase in observation stays reflects a lack of proper care for patients placed in observation status.

Patient, hospital, and local health system characteristics associated with the use of observation stays in veterans health administration hospitals, 2005 to 2012.

Recent studies have documented that a significant increase in the use of observation stays along with extensive variation in patterns of use across hospitals.The objective of this longitudinal observational study was to examine the extent to which patient, hospital, and local health system characteristics explain variation in observation stay rates across Veterans Health Administration (VHA) hospitals.Our data came from years 2005 to 2012 of the nationwide VHA Medical SAS inpatient and enrollment files, American Hospital Association Survey, and Area Health Resource File. We used these data to estimate linear regression models of hospitals' observation stay rates as a function of hospital, patient, and local health system characteristics, while controlling for time trends and Veterans Integrated Service Network level fixed effects.We found that observation stay rates are inversely related to hospital bed size and that hospitals with a greater proportion of younger or rural patients have higher observation stay rates. Observation stay rates were nearly 15 percentage points higher in 2012 than 2005.Although we identify several characteristics associated with variation in VHA hospital observation stay rates, many factors remain unmeasured.

Chest Pain Patients at Veterans Hospitals Are Increasingly More Likely to Be Observed Than Admitted for Short Stays.

Observation stays are an outpatient service used to diagnose and treat patients for extended periods of time while a decision is made regarding inpatient admission or discharge. Although the use of observation stays is increasing, little is known about which patients are observed and which are admitted for similar periods of time as inpatients. The aim was to identify patient characteristics associated with being observed rather than admitted for a short stay (<48 hours) within the Veterans Health Administration (VHA). In our longitudinal analysis, we used logistic regression within a generalized estimating equation framework to model observation stays as a function of patient characteristics, time trends, and hospital fixed effects. To minimize heterogeneity between groups, we limit our sample to patients with a presenting diagnosis of chest pain. Our analysis includes a total of 121 584 hospital events, which consist of all observation and short-stay admissions for chest pain patients at VHA hospitals between 2005 and 2013. Both the absolute and relative use of observation stays increased markedly over time. The odds of an observation stay were higher among women, but lower among older patients and rural residents. Despite strong evidence that chest pain patients are increasingly more likely to be observed than admitted, suggesting a substitution effect, we find little evidence of within-hospital disparities in VHA observation stay use.

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.

Medicare Part D and Portfolio Choice.

This study evaluates the impact of medical expenditure risk on portfolio choice among the elderly. The risk of large medical expenditures can be substantial for elderly individuals and is only partially mitigated by access to health insurance. The presence of deductibles, copayments, and other cost-sharing mechanisms implies that medical spending risk can be viewed as an undiversifiable background risk. Economic theory suggests that increases in background risk reduce the optimal financial risk that an individual or household is willing to bear (Pratt and Zeckhauser 1987; Elmendorf and Kimball 2000). In this study, we evaluate this hypothesis by estimating the impact of the introduction of the Medicare Part D program, which significantly reduced prescription drug spending risk for seniors, on portfolio choice.

Observation Rates At Veterans' Hospitals More Than Doubled During 2005-13, Similar To Medicare Trends.

When neither inpatient admission nor prompt discharge is clearly indicated for a patient in the emergency department, physicians place the patient under observation in a hospital for diagnosis and treatment. The increasing prevalence of observation stays at hospitals reimbursed by Medicare is receiving considerable attention, but the prevalence remains unexplored in Veterans Health Administration (VHA) hospitals, which are subject to different payment policies. Using VHA data for fiscal years 2005-13, we identified trends and variations in observation rates across twenty-one Veteran Integrated Service Networks and 128 VHA hospitals nationwide. We found that observation rates across VHA hospitals more than doubled, from 6.5 percent to 13.8 percent, and that there was substantial variation across both Veteran Integrated Service Networks and hospitals. The most prevalent diagnoses accounted for an increasing share of observation stays over time. Despite different incentives within the VHA and Medicare, rates of observation have increased over time for both populations.

The Business Case for Tele-emergency.

BACKGROUND: Tele-emergency is an expanding telehealth service that provides real-time audio/visual consultation delivered by an emergency medicine team to a remote, often rural, emergency department (ED). Financial analyses of tele-emergency in the literature are limited. This article expands the tele-emergency literature to describe the business case for tele-emergency. "Business case" is defined as a reasoned argument, supported by objective data and/or qualitative judgment, to implement or continue a service or product. MATERIALS AND METHODS: To evaluate tele-emergency financing from the perspective of a critical access hospital (CAH), 10 financial analysis categories were defined. Telephone interviews, site visits, and financial data from the eEmergency program of Avera Health (Sioux Falls, SD) were used to populate the categories. Avera Health information was augmented with national data where available. Three financial scenarios were then analyzed for CAH profit/loss associated with tele-emergency. RESULTS: Tele-emergency financial analysis demonstrated an $187,614 profit in a high revenue/low expense scenario, $49,841 profit in a midrange scenario, and $69,588 loss in a low revenue/high expense scenario. CONCLUSIONS: Tele-emergency may be a profitable rural hospital service line if the participating hospital adjusts ED processes to take advantage of increased revenue/savings opportunities afforded by tele-emergency. Savings due to tele-emergency primarily accrue when physician ED backup and physician ED staffing costs are substituted.

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.

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

OBJECTIVES: To assess whether the Affordable Care Act's (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.

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.

Lower extremity function trajectories in the African American Health Cohort.

BACKGROUND: We addressed two understudied issues in estimating lower extremity functional trajectories in older adults-incorporating the effect of mortality and evaluating heterogeneity among African Americans. METHODS: Data were taken from the 998 participants in the African American Health cohort. A highly reliable and valid 8-item lower extremity function scale was used at baseline and at the 1-, 2-, 3-, 4-, 7-, and 9-year follow-up interviews. Semiparametric (ie, discrete) group-based mixture modeling identified the trajectories, and multinomial logistic regression identified risk factors for differential trajectory groups. RESULTS: When treating mortality as informative censoring, six discrete trajectories were observed with 45% of the participants belonging to three stable trajectories (good, fair, or poor function), and the remainder belonging to three declining trajectories (very high function with minimal improvement then minimal decline, very good function with a slow and modest decline, and very good function with a large and quick decline). CONCLUSION: Substantial heterogeneity in lower extremity function trajectories exists in the African American Health cohort, after appropriately treating mortality as informative censoring.

Understanding heterogeneity in price elasticities in the demand for alcohol for older individuals.

This paper estimates the price elasticity of demand for alcohol using Health and Retirement Study data. To account for unobserved heterogeneity in price responsiveness, we use finite mixture models. We recover two latent groups, one is significantly responsive to price, but the other is unresponsive. The group with greater responsiveness is disadvantaged in multiple domains, including health, financial resources, education and perhaps even planning abilities. These results have policy implications. The unresponsive group drinks more heavily, suggesting that a higher tax would fail to curb the negative alcohol-related externalities. In contrast, the more disadvantaged group is more responsive to price, thus suffering greater deadweight loss, yet this group consumes fewer drinks per day and might be less likely to impose negative externalities.