The impacts of supplemental benefits on Medicare Advantage plan composition.

OBJECTIVES: In 2019 and 2020, Medicare Advantage (MA) plans received historic flexibility to begin to address members' nonmedical and social needs through a set of primarily health-related benefits (PHRBs) and Special Supplemental Benefits for the Chronically Ill (SSBCIs). We aimed to evaluate the impact of adoption on the number and composition of new MA plan enrollees. STUDY DESIGN: A difference-in-differences design of retrospective Medicare enrollment data linked to publicly available plan and county-level data. METHODS: We linked individual-level Medicare enrollment data to publicly available, plan-level MA benefit, crosswalk, and penetration files from 2016 to 2020. We compared the number of new enrollees and the proportion of new enrollees who were Black, Hispanic, younger than 65 years, partially and fully Medicare and Medicaid dual eligible, and disabled in plans that adopted a PHRB or SSBCI vs a set of matched control plans that did not. RESULTS: In fully adjusted models, PHRB adoption was associated with a 2.2% decrease in the proportion of fully dual-eligible new members (95% CI, -4.0% to -0.5%). SSBCI adoption was associated with a 2.3% decrease in the proportion of new members younger than 65 years (95% CI, -3.6% to -0.9%). After accounting for multiple comparisons, these results were no longer statistically significant. CONCLUSION: We determined that supplemental benefit adoption was not associated with demographic shifts in MA plan enrollment.

Medical insurance benefits and health inequality: evidence from rural China.

Alleviating health inequality among different income groups has become a significant policy goal in China to promote common prosperity. Based on the data from the China Health and Retirement Longitudinal Study (CHARLS) covering the period from 2013 to 2018, this study empirically examines the impact of Integrated Medical Insurance System (URRBMI) on the health and health inequality of older adult rural residents. The following conclusions are drawn: First, URRBMI have elevated the level of medical security, reduced the frailty index of rural residents, and improved the health status of rural residents. Second, China exhibits "pro-rich" health inequality, and URRBMI exacerbates health inequality among rural residents with different incomes. This result remains robust when replacing the frailty index with different health modules. Third, the analysis of influencing mechanisms indicates that the URRBMI exacerbate inequality in the utilization of medical services among rural residents, resulting in a phenomenon of "subsidizing the rich by the poor" and intensifying health inequality. Fourth, in terms of heterogeneity, URRBMI have significantly widened health inequality among the older adult and in regions with a higher proportion of multiple-tiered medical insurance schemes. Finally, it is suggested that China consider establishing a medical financing and benefit assurance system that is related to income and age and separately construct a unified public medical insurance system for the older adult population.

New Supplemental Benefits and Plan Ratings Among Medicare Advantage Enrollees.

Importance: In 2018, the US Congress gave Medicare Advantage (MA) historic flexibility to address members' social needs with a set of Special Supplemental Benefits for the Chronically Ill (SSBCIs). In response, the Centers for Medicare & Medicaid Services expanded the definition of primarily health-related benefits (PHRBs) to include nonmedical services in 2019. Uptake has been modest; MA plans cited a lack of evidence as a limiting factor. Objective: To evaluate the association between adopting the expanded supplemental benefits designed to address MA enrollees' nonmedical and social needs and enrollees' plan ratings. Design, Setting, and Participants: This cohort study compared the plan ratings of MA enrollees in plans that adopted an expanded PHRB, SSBCI, or both using difference-in-differences estimators with MA Consumer Assessment of Health Care Providers and Systems survey data from March to June 2017, 2018, 2019, and 2021 linked to Medicare administrative claims and publicly available benefits and enrollment data. Data analysis was performed between April 2023 and March 2024. Exposure: Enrollees in MA plans that adopted a PHRB and/or SSBCI in 2021. Main Outcomes and Measures: Enrollee plan rating on a 0- to 10-point scale, with 0 indicating the worst health plan possible and 10 indicating the best health plan possible. Results: The study sample included 388 356 responses representing 467 MA contracts and 2558 plans in 2021. Within the weighted population of responders, the mean (SD) age was 74.6 (8.7) years, 57.2% were female, 8.9% were fully Medicare-Medicaid dual eligible, 74.6% had at least 1 chronic medical condition, 13.7% had not graduated high school, 9.7% were helped by a proxy, 45.1% reported fair or poor physical health, and 15.6% were entitled to Medicare due to disability. Adopting both a new PHRB and SSBCI benefit in 2021 was associated with an increase of 0.22 out of 10 points (95% CI, 0.4-4.0 points) in mean enrollee plan ratings. There was no association between adoption of only a PHRB (adjusted difference, -0.12 points; 95% CI, -0.26 to 0.02 points) or SSBCI (adjusted difference, 0.09 points; 95% CI, -0.03 to 0.21 points) and plan rating. Conclusions and Relevance: Medicare Advantage plans that adopted both benefits saw modest increases in mean enrollee plan ratings. This evidence suggests that more investments in supplemental benefits were associated with improved plan experiences, which could contribute to improved plan quality ratings.

Does the increase in health insurance benefits have different effects on the health of middle-aged and older people individuals in rural areas? Analysis based on quantile difference-in-differences method.

In the context of healthy aging, enhancing health performance is an intrinsic requirement for the development and reform of the health insurance system. This paper mainly discusses the health effects of increasing medical insurance benefits on people with different levels of health. So this paper utilizes multiple rounds of data from the China Health and Retirement Longitudinal Study (CHARLS) and employs the quantile difference-in-differences method to systematically investigate the impact effects of the integration of urban and rural residents' health insurance on the frailty levels of rural middle-aged and older people individuals. The research findings are as follows: Firstly, the integration of urban and rural resident health insurance has mitigated the frailty level of rural older people individuals, with a more pronounced impact on those with poorer health statuses. Secondly, in terms of heterogeneity analysis, the health performance effects of the urban-rural health insurance integration policy are more significant among the older people population and in the western regions. Thirdly, the integration of urban and rural resident health insurance primarily improves health by reducing the burden of medical expenses, with a greater impact on the older people population with poorer health statuses. Based on the research findings, we recommend addressing the disparities in healthcare benefits across various insurance systems, alleviating the financial burden of healthcare for impoverished individuals, and consistently improving the coordination of healthcare insurance policies for both urban and rural residents.

The Rise and Risks of Medicare Advantage "Affinity Plans".

This Viewpoint discusses the proliferation of Medicare Advantage plans targeting specific groups of individuals and whether these plans will improve quality of care for beneficiaries.

Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults.

This study examines the association of partner Medicare Advantage plan status over 1 year with beneficiary and plan characteristics.

Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries.

Importance: American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited. Objective: To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance. Design, Setting, and Participants: This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023. Main Outcomes and Measures: The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]). Results: Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients). Conclusions and Relevance: In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.

Cost sharing for breast cancer hormone therapy: How do dual eligible patients' copayment impact adherence.

OBJECTIVE: To examine the different levels of copayment assistance and treatment adherence among Medicare and Medicaid dual eligible beneficiaries with breast cancer in the U.S. RESEARCH DESIGN: Propensity Score methodology was adopted to minimize potential selection bias from the nonrandom allocation of the treatment group (i.e., full Medicaid beneficiaries) and control group (i.e., Medicare Savings Programs [MSPs] beneficiaries). Longitudinal hierarchical model and Cox proportional-hazard model were adopted to examine patients' adherence over their full five-year course of adjuvant hormone therapy. RESULTS: Our study cohort consisted of 1,133 dual eligible beneficiaries diagnosed with hormone receptor-positive early stage breast cancer in years 2007 -mid 2009. About 80.5% of them received MSPs benefits, while the rest received full Medicaid benefits. On average for a standardized 30-day hormone therapy medication, full Medicaid beneficiaries spent $0.5-$2.0 and MSP beneficiaries spent $1.4-$4.8 in copayment. After adjusting for other factors, this copayment reduction wasn't associated with a significantly better adherence. However, when the catastrophic coverage threshold was reached (copayments reduced to zero), significant improvement in adherence was found in both groups. CONCLUSIONS: Our study found that small amount of cost-sharing reduction did not affect Medicare and Medicaid dual eligible patients' medication treatment adherence, however, the elimination of cost-sharing (even a minimal amount) was associated with improved adherence. Future legislative and advocacy efforts should be paid on eliminating cost sharing for dual eligibles, and possibly even a broader group of financially vulnerable patients.

Migrant workers, essential work, and COVID-19.

Globally, migrant and immigrant workers have borne the brunt of the COVID-19 pandemic as essential workers. They might be a Bulgarian worker at a meat processing plant in Germany, a Central American farmworker in the fields of California, or a Filipino worker at an aged-care facility in Australia. What they have in common is they are all essential workers who have worked throughout the coronavirus pandemic and have been infected with coronavirus at work. COVID-19 has highlighted the inequitable working conditions of these workers. In many instances, they are employed precariously, and so are ineligible for sick leave or social security, or COVID-19 special payments. If these are essential workers, they should get at least the same health and safety benefits of all nonessential workers. Improving the working and living conditions of migrant workers can and should be a positive outcome of the coronavirus pandemic.

Telehealth Benefits Offered by Medicare Advantage Plans in 2020.

OBJECTIVE: The objective of this study was to analyze new telehealth benefits offered by Medicare Advantage (MA) plans in 2020 and examine plan characteristics associated with the provision of the new telehealth benefits. RESEARCH DESIGN: Using publicly available data from the Centers for Medicare and Medicaid Services, we identified unique MA plans with at least 1 enrollee in January 2020. We examined whether plans offered any new telehealth benefits in 2020, the 20 most common types of telehealth services covered, and cost-sharing. Next, we used multivariable logistic regression to identify associations between offering any telehealth benefits and plan characteristics. We conducted a similar analysis for each of the 3 most commonly covered telehealth services. RESULTS: Of 2992 unique MA plans, 58.1% offered new telehealth benefits in 2020. The most frequently covered services were primary care, mental health, and urgent care. Coverage for other types of services was limited. Our multivariable logistic regression showed that offering any new telehealth benefits was not more common among plans in rural areas, but was more likely among national plans, those with a monthly premium, those with >3540 enrollees, and those with a star rating of 4.0-4.5. The new telehealth benefits were less likely to be provided by for-profit plans. Overall, findings remained similar when analyzed according to the type of services. CONCLUSIONS: MA plans are embracing new telehealth benefits, but there is room for improvement. Policymakers should consider how to accelerate the adoption curve of telehealth in MA plans.

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries.

BACKGROUND: Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences. RESEARCH OBJECTIVE: Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs). STUDY DESIGN: Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata. RESULTS: Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs. CONCLUSIONS: There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.

Assessment of hospital quality and safety standards among Medicare beneficiaries undergoing surgery for cancer.

BACKGROUND: We sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer. METHODS: Standard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition. RESULTS: Among 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76-0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82-0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06-1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10-1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21-1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90-1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98-1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes. CONCLUSION: Quality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.

Ethnic disparities in receiving benefits for disability following postpartum mental illness during first two years after delivery: an Israeli nationwide study.

BACKGROUND: Despite relatively high rates of Postpartum Depression (PPD), little is known about the granting of social security benefits to women who are disabled as a result of PPD or of other postpartum mood and anxiety disorders (PMAD). This study aims to identify populations at risk for underutilization of social security benefits due to PMAD among Israeli women, with a focus on ethnic minorities. METHODS: This retrospective cohort study is based on the National Insurance Institute (NII) database. The study population included a simple 10% random sample of 79,391 female Israeli citizens who gave birth during 2008-2016 (these women delivered a total of 143,871 infants during the study period), and who had not been eligible for NII mental health disability benefits before 2008. The dependent variable was receipt of Benefit Entitlement (BE) due to mental illness within 2 years following childbirth. Maternal age at delivery, population group, Socio-Economic Status (SES), family status, employment status of the mother and her spouse, and infant mortality were the independent variables. Left truncation COX proportional hazard model with time-dependent variables was used, and birth number served as a time discrete variable. RESULTS: Bedouin and Arab women had significantly lower likelihood of BE (2.6 times lower and twice lower) compared with other ethnic groups (HR = 0.38; 95% CI: 0.26-0.56; HR = 0.47; 95% CI: 0.37-0.60 respectively). The probability of divorced or widowed women for BE was significantly higher compared to those living with a spouse (HR = 3.64; 95% CI: 2.49-5.33). Lack of employment was associated with higher likelihood of BE (HR = 1.54; 95% CI: 1.30-1.82). Income had a dose-response relationship with BE in multivariable analysis: lower income was associated with the nearly four-fold greater probability compared to the highest income quartile (HR = 3.83; 95% CI: 2.89-5.07). CONCLUSIONS: Despite the exceptionally high prevalence of PMAD among ethnic minorities, Bedouins and Arabs had lowest likelihood of Benefit Entitlement. In addition to developing programs for early identification of postpartum emotional disorders among unprivileged ethnic groups, awareness regarding entitlement to a mental health disability allowance among ethnic minorities should be improved.

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees.

Importance: Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. Objective: To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. Design, Setting, and Participants: This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Exposures: Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Main Outcomes and Measures: Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. Results: The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). Conclusions and Relevance: This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.

A decade of experience for high-needs beneficiaries under Medicare Advantage.

OBJECTIVE: To describe the association between longitudinal enrollment in Medicare Advantage (MA) and utilization, access, quality of care, and health outcomes for beneficiaries with complex health needs. DATA SOURCES/STUDY SETTING: Beneficiary characteristics, enrollment, and outcomes data from the 2004-2016 waves of the Health and Retirement Study (HRS). STUDY DESIGN: Using the HRS panel structure, we identified beneficiaries consistently reporting high needs as well as enrollment in MA versus traditional Medicare (TM). We first evaluated a robust set of beneficiary characteristics to identify those that distinguish beneficiaries who consistently enrolled in MA versus TM. We then described adjusted differences in outcomes between high-needs beneficiaries who consistently enrolled in MA versus TM. PRINCIPAL FINDINGS: Among high-needs beneficiaries, there was a modest amount of favorable selection into MA based on health. Controlling for several characteristics, MA enrollees used less care (with a 6.6 percentage point (pp) lower probability of hospitalization, 4.7 fewer physician visits, and a 5.1 pp lower probability of using home health care), had a 4.1 pp greater probability of being unable to afford their care, and had a 5.7 pp lower probability of reporting that they were very satisfied with their care. Compared to associations between MA and outcomes for high-needs beneficiaries, for non-high-needs beneficiaries MA enrollment was associated with smaller decreases in utilization and no statistically significant difference in the inability to afford care. CONCLUSIONS: Our descriptive findings raise the possibility that high-needs beneficiaries may experience unique challenges in MA compared to their non-high-needs counterparts.

Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia.

Importance: There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States. Objective: To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis. Design, Setting, and Participants: This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties. Exposures: Rurality of beneficiary's county of residence. Main Outcomes and Measures: Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services. Results: A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis. Conclusions and Relevance: Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.

Early Determinants of Work Disability in an International Perspective.

This study explores the interrelated roles of health and welfare state policies in the decision to take up disability insurance (DI) benefits due to work disability (WD), defined as the (partial) inability to engage in gainful employment as a result of physical or mental illness. We exploit the large international variation of health, self-reported WD, and the uptake of DI benefits in the United States and Europe using a harmonized data set with life history information assembled from SHARE, ELSA, and HRS. We find that the mismatch between WD and DI benefit receipt varies greatly across countries. Objective health explains a substantial share of the within-country variation in DI, but this is not the case for the variation across countries. Rather, most of the variation between countries and the mismatches are explained by differences in DI policies.

Inequity under equality: research on the benefits equity of Chinese basic medical insurance.

BACKGROUND: The pursuit of equity is one of the basic principles behind the strengthening of health care reform. China's new rural cooperative medical insurance (NRCMI) and urban residents' basic medical insurance (URBMI) are both "equalized" in terms of fundraising and reimbursement. This paper studies the benefits equity under this "equalized" system. METHODS: The data analysed in this paper are from the China Family Panel Studies (CFPS) from 2014 to 2016, implemented by the Institute of Social Science Survey at Peking University. A two-part model and a binary choice model are used in the empirical test. RESULTS: The empirical test revealed that high-income people benefit more from basic medical insurance than low-income people. Mechanism analysis demonstrated that high-income people have higher medical insurance applicability and can utilize better health care. Since low-income people are unhealthier, inequity in benefits exacerbates health inequity. We also found that the benefits equity of URBMI is better than that of NRCMI. CONCLUSIONS: The government needs to pay more attention to the issue of medical insurance inequity. We should consider allowing different income groups to pay different premiums according to their medical expenses or applying different reimbursement policies for different income groups.