Person:

Blendon, Robert

Objective: To discern how the public in four countries, each with unique health systems and cultures, feels about efforts to restrain healthcare costs by limiting the use of high-cost prescription drugs and medical/surgical treatments. Design: Cross-sectional survey. Setting: Adult populations in Germany, Italy, the UK and the USA. Participants: 2517 adults in the four countries. A questionnaire survey conducted by telephone (landline and cell) with randomly selected adults in each of the four countries. Main outcome measures: Support for different rationales for not providing/paying for high-cost prescription drugs/medical or surgical treatments, measured in the aggregate and using four case examples derived from actual decisions. Measures of public attitudes about specific policies involving comparative effectiveness and cost-benefit decision making. Results: The survey finds support among publics in four countries for decisions that limit the use of high-cost prescription drugs/treatments when some other drug/treatment is available that works equally well but costs less. The survey finds little public support, either in individual case examples or when asked in the aggregate, for decisions in which prescription drugs/treatments are denied on the basis of cost or various definitions of benefits. The main results are based on majorities of the public in each country supporting or opposing each measure. Conclusions: The survey findings indicate that the public distinguishes in practice between the concepts of comparative effectiveness and cost-effectiveness analysis. This suggests that public authorities engaged in decision-making activities will find much more public support if they are dealing with the first type of decision than with the second.

The objective of this paper is to understand how the public's beliefs in five countries may change as more families have direct experience with Alzheimer's disease. The data are derived from a questionnaire survey conducted by telephone (landline and cell) with 2678 randomly selected adults in France, Germany, Poland, Spain, and the United States. The paper analyzes the beliefs and anticipated behavior of those in each country who report having had a family member with Alzheimer's disease versus those who do not. In one or more countries, differences were found between the two groups in their concern about getting Alzheimer's disease, knowledge that the disease is fatal, awareness of certain symptoms, and support for increased public spending. The results suggest that as more people have experience with a family member who has Alzheimer's disease, the public will generally become more concerned about Alzheimer's disease and more likely to recognize that Alzheimer's disease is a fatal disease. The findings suggest that other beliefs may only be affected if there are future major educational campaigns about the disease. The publics in individual countries, with differing cultures and health systems, are likely to respond in different ways as more families have experience with Alzheimer's disease.

Results from a national survey indicated that most persons would follow public health officials’ guidelines. We report the results of a national survey conducted to help public health officials understand the public’s response to community mitigation interventions for a severe outbreak of pandemic influenza. Survey results suggest that if community mitigation measures are instituted, most respondents would comply with recommendations but would be challenged to do so if their income or job were severely compromised. The results also indicate that community mitigation measures could cause problems for persons with lower incomes and for racial and ethnic minorities. Twenty-four percent of respondents said that they would not have anyone available to take care of them if they became sick with pandemic influenza. Given these results, planning and public engagement will be needed to encourage the public to be prepared.

States are taking variable approaches to the Affordable Care Act (ACA) Medicaid expansion, Marketplace design, enrollment outreach, and application assistance. We surveyed nearly 3,000 low-income adults in late 2014 to compare experiences in three states with markedly different policies: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed restrictions on navigators. We found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst. Limited awareness remains a critical barrier: Fewer than half of adults had heard some or a lot about the coverage expansions. Application assistance from navigators and others was the strongest predictor of enrollment, while Latino applicants were less likely than others to successfully enroll. Twice as many respondents felt that the ACA had helped them as hurt them (although the majority reported no direct impact), and advertising was strongly associated with perceptions of the law. State policy choices appeared to have had major impacts on enrollment experiences among low-income adults and their perceptions of the ACA.

Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the “private option”). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November–December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky’s traditional Medicaid expansion and Arkansas’s private option, which suggests that both approaches improved access among low-income adults.

Context: The Affordable Care Act (ACA) has reduced the U.S.’s uninsured rate to an historic low. But coverage is only one of many factors contributing to racial and income-based disparities in health care access, affordability, and quality.

Methods: Using a novel 2015 national survey of over 8,000 Americans, we examined disparities between low-income and high-income adults, and between racial/ethnic minorities and whites. We conducted a series of regression analyses, starting with models that only took into account income or race, and then sequentially adjusted for health insurance, state of residence, demographics, and health status. We examined self-reported quality of care, cost-related delays in care, and emergency department (ED) use due to lack of available appointments. Then we used multivariate regression to assess respondents’ views of whether quality and affordability had improved over the past two years and whether the ACA was helping them.

Findings: Quality of care ratings were significantly worse among lower-income adults than higher-income adults. Only 10-25% of this gap was explained by health insurance coverage. Cost-related delays in care and ED use due to lack of available appointments were nearly twice as common in the lowest-income group, and less than 40% of these disparities was explained by insurance. There were significant racial/ethnic gaps: reported quality of care was worse among blacks and Latinos than whites, with 16-70% explained by insurance. In contrast to these disparities, lower-income and minority groups were generally more likely than whites or higher-income adults to say that the ACA was helping them and that the quality and/or affordability of care had improved in recent years.

Conclusions: Our post-health reform survey shows ongoing stark income and racial disparities in the health care experiences of Americans. While the ACA has narrowed these gaps, insurance expansion alone will not be enough to achieve health care equity.

Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA’s coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in “excellent” self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health.

Changes in insurance coverage over time, or “churning,” may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a “private option” expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months—a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts.

Background: As public health leaders prepare for possible future influenza pandemics, the rapid spread of 2009 H1N1 influenza highlights the need to focus on measures the public can adopt to help slow disease transmission. Such measures may relate to hygiene (e.g., hand washing), social distancing (e.g., avoiding places where many people gather), and pharmaceutical interventions (e.g., vaccination). Given the disproportionate impact of public health emergencies on minority communities in the United States, it is important to understand whether there are differences in acceptance across racial/ethnic groups that could lead to targeted and more effective policies and communications. Objectives: This study explores racial/ethnic differences in the adoption of preventive behaviors during the 2009 H1N1 influenza pandemic. Patients/Methods Data are from a national telephone poll conducted March 17 to April 11, 2010, among a representative sample of 1123 white, 330 African American, 317 Hispanic, 268 Asian, and 262 American Indian/Alaska Native adults in the USA. Results: People in at least one racial/ethnic minority group were more likely than whites to adopt several behaviors related to hygiene, social distancing, and healthcare access, including increased hand washing and talking with a healthcare provider (P-values <0·05). Exceptions included avoiding others with influenza-like illnesses and receiving 2009 H1N1 and seasonal influenza vaccinations. After we controlled the data for socioeconomic status, demographic factors, healthcare access, and illness- and vaccine-related attitudes, nearly all racial/ethnic differences in behaviors persisted. Conclusions: Minority groups appear to be receptive to several preventive behaviors, but barriers to vaccination are more pervasive.

Importance Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the “private option”). In addition, while coverage gains from the ACA’s Medicaid expansion are well documented, impacts on utilization and health are unclear.

Objective To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA.

Design, Setting, and Participants Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016.

Exposures Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas.

Main Outcomes and Measures Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health.

Results Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (−11.6 percentage points; P < .001), reduced out-of-pocket spending (−29.5%; P = .02), reduced likelihood of emergency department visits (−6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (−7.1 percentage points with “fair/poor quality of care”; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P  < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences.

Conclusions and Relevance In the second year of expansion, Kentucky’s Medicaid program and Arkansas’s private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.