By any measure, the United States has a level of health inequity rarely seen among developed nations. The roots of this inequity are deep and complex, and are a function of differences in income, education, race and segregation, and place. In this primer, we provide an overview of these distinctly American problems, and discuss programs and policies that might promote greater health equity in the population.
Calls for the establishment of a “public option,” which emerged during the debate on the Affordable Care Act, have reemerged in this election season. Some proposals base the public option on Medicare, while others on Medicaid. In this article, Wharton professor and LDI Senior Fellow Mark Pauly discusses the likely effects of a public option on private markets, using experience in Medicare Advantage as a guide. Will the public option become the preferred one, sweeping away the private market? Or can the public and private options peacefully coexist?
In the United States, people who need long-term care (LTC) face a system with large gaps in care, which they must rely on friends and family to fill. Medicaid finances the majority of paid LTC, but people must exhaust their resources to qualify. Medicare and private health insurance do not cover LTC, and the private market for long-term care insurance is failing. Unpaid family and friends provide most long-term services, but the value of their services is rarely reflected in debates about LTC financing and delivery. Beyond the value of the services, this system has costs to the economy, as spouses and adult children reduce paid work to care for their loved ones. As the population ages and families are less able to shoulder the burden of LTC, the current system may be unable to meet the growing need without an alternative, sustainable financing mechanism.
Prior to the Affordable Care Act (ACA), health care safety-net programs were the primary source of care for over 44 million uninsured people. While the ACA cut the number of uninsured substantially, about 30 million people remain uninsured, and many millions more are vulnerable to out-of-pocket costs beyond their resources. The need for the safety net remains, even as the distribution and types of need have shifted. This brief reviews the effects of the ACA on the funding and operation of safety-net institutions. It highlights the challenges and opportunities that health care reform presents to safety-net programs, and how they have adapted and evolved to continue to serve our most vulnerable residents.
Amidst an ongoing opioid crisis that claimed 47,600 lives in 2017, increasing the availability of the rescue medication naloxone is a high priority. Naloxone reverses an opioid overdose when given intranasally or intramuscularly. But to be effective, naloxone must be available at the time of overdose. Naloxone distribution to laypeople can save a life when first responders are not immediately available, or when people witnessing overdoses are unwilling or unable to call 911. Naloxone is increasingly available through some pharmacies under a standing order; however, even when available, cost and stigma barriers persist. This Issue Brief reviews recent evidence on the outcomes and cost-effectiveness of naloxone distribution strategies in community, pharmacy, and other health care settings.
Growing concern about the affordability of health care and the cost burden imposed on working families frequently appears in public debate about the next phase of health care reform. In this second brief of our affordability series, Penn LDI and United States of Care adapt a national-level affordability index to provide state-level data on the cost burden faced by working families who have employer-sponsored insurance (ESI). We examine how this burden varies across states, and how it has changed within states from 2010 to 2016.
In our initial report “Detecting BS in Health Care,” we identified our top ten BS concepts and trends within the health care industry, and encouraged our readers to hone their “BS detection skills.” Many of you have let us know that we “left some BS on the table.” This time around, we make bolder assertions about other possible forms of BS—including some sacred cows—that might make some readers uncomfortable.
To help the Pennsylvania Department of Human Services understand the likely impact of a proposed Medicaid work requirement, we analyzed the demographic, economic and health characteristics of working-age, non-disabled adults who receive Medicaid, and any issues or barriers this population may face in obtaining and maintaining employment.
In the past several months, we have observed several notable signs of deceptive, misleading, unsubstantiated, and foolish statements — what we will call “BS” — in the health care industry. Here we present our Top 10 BS candidates, in both pictures and words. First we present each picture, untitled and without text, thereby inviting readers to discern what the BS message is and engage them in the BS detection process. Then we offer an explanation of what the picture conveys. This will help the reader become a more skilled “BS Hunter.” We reserve the option to expound further as we step in more BS in the future.
Although the “affordability” of health care is a common concern, the term is rarely defined.This joint Penn LDI and United States of Care issue brief considers affordability as an economic concept, as a kitchen-table budget issue for individuals and families, and as a threshold in current policy. It reviews a range of measures that capture the cost burden for individuals and families with different forms of coverage, in different financial circumstances, and with different health concerns.
Supply of Primary Care Providers and Appointment Availability for Philadelphia's Medicaid Population
This brief analyzes the supply of primary care providers serving the Medicaid population in Philadelphia, and the geographic variability of this measure across the city. It also examines important measures of access – appointment availability and wait time for an initial appointment – that highlight challenges faced by Medicaid patients.
A review of the evidence shows that bundled payments for surgical procedures can generate savings without adversely affecting patient outcomes. Less is known about the effect of bundled payments for chronic medical conditions, but early evidence suggests that cost and quality improvements may be small or non-existent. There is little evidence that bundles reduce access and equity, but continued monitoring is required.
In just five years, hepatitis C has changed from a difficult-to-treat chronic condition to one that is readily cured by a short course of medication. Medical breakthroughs have now created the possibility of eliminating the transmission of HCV, but also bring a new challenge for the health system—how to identify individuals carrying the hepatitis C virus (HCV), and how to pay for life-saving treatments. This Issue Brief reviews recent evidence on the cost-effectiveness of screening and treatment strategies, and makes the case for universal, one-time HCV screening for all US adults.
In response to regulatory changes at the federal level, states that run their own marketplaces have taken steps to stabilize their individual markets. In this comparison of state-based and federally-facilitated marketplaces from 2016-2018, we find that SBMs had slower premium increases (43% vs. 75%), and fewer carrier exits, than FFMs. The total population participating in FFMs declined by 10%, while the enrolled population in SBMs remained largely stable, increasing by 2%. We find that the performance of the ACA marketplaces varies by state and appears to cluster around marketplace types.
The prevalence of narrow provider networks on the ACA Marketplace is trending down. In 2017, 21% of plans had narrow networks, down from 25% in 2016. The largest single factor was that 70% of plans from National carriers exited the market and these plans had narrower networks than returning plans. Exits account for more than half of the decline in the prevalence of narrow networks, with the rest attributed to broadening networks among stable plans, particularly among Blues carriers. The narrow network strategy is expanding among traditional Medicaid carriers and remains steady among provider-based carriers and regional/local carriers.