CONTEXT Provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA) expand Medicaid to all individuals in families earning less than 133 percent of the federal poverty level (FPL) and make available subsidies to uninsured lower-income Americans (133 to 400 percent of FPL) without access to employer-based coverage to purchase insurance in new exchanges. Since primary care physicians typically serve as the point of entry into the health care delivery system, an adequate supply of them is critical to meeting the anticipated increase in demand for medical care resulting from the expansion of coverage. This article provides state-level estimates of the anticipated increases in primary care utilization given the PPACA's provisions for expanded coverage. METHODS Using the Medical Expenditure Panel Survey, this article estimates a multivariate regression model of annual primary care utilization. Using the model estimates and state-level information regarding the number of uninsured, it predicts, by state, the change in primary care visits expected from the expanded coverage. Finally, the article predicts the number of primary care physicians needed to accommodate this change in utilization. FINDINGS This expanded coverage is predicted to increase by 2019 the number of annual primary care visits between 15.07 million and 24.26 million. Assuming stable levels of physicians' productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase. CONCLUSIONS The PPACA's health insurance expansion parameters are expected to significantly increase the use of primary care. Two strategies that policymakers may consider are creating stronger financial incentives to attract medical school students to primary care and changing the delivery of care in ways that lead to operational improvements, higher throughput, and better quality of care.

BACKGROUND: Research into nursing home transitions has given limited attention to the facility or community contexts. OBJECTIVE: To identify facility and market factors affecting transitions of nursing home residents back to the community. RESEARCH DESIGN: Multilevel models were used to estimate effects of facility and market factors on facility-level community discharge rates after controlling for resident demographic, health, and functional conditions. Facility discharge rates were adjusted using Empirical Bayes estimation. SUBJECTS: Annual cohort of first-time admissions (N=24,648) to 378 Minnesota nursing facilities in 75 nursing home markets from July 2005 to June 2006. MEASURES: Community discharge within 90 days of admission; facility occupancy, payer mix, ownership, case-mix acuity, size, admissions from hospitals, nurse staffing level, and proportion of admissions preferring or having support to return to the community; and nursing market population size, average occupancy, market concentration, and availability of home and community-based services. RESULTS: Rates of community discharge (Empirical Bayes residual) were highest in facilities with more residents preferring community discharge, more Medicare days, higher nurse staffing levels, and higher occupancy. In addition, facilities had higher community discharge rates if they were located in markets with a greater ratio of home and community-based services recipients to nursing home residents and with larger populations. CONCLUSIONS: State Medicaid programs should undertake system-level interventions that encourage nursing facilities to reduce unused bed capacity, balance the mix of payers, invest in nurse staffing, and take other steps to promote community discharges. In addition, states should increase home and community-based services, particularly in markets with low community discharge rates.

OBJECTIVE To provide state-level estimates of the size and structure of the US individual market for health insurance and to investigate the potential impact of new medical loss ratio (MLR) regulation in 2011, as indicated by the Patient Protection and Affordable Care Act (PPACA). STUDY DESIGN Using data from the National Association of Insurance Commissioners, we provided state-level estimates of the size and structure of the US individual market from 2002 to 2009. We estimated the number of insurers expected to have MLRs below the legislated minimum and their corresponding enrollment. In the case of noncompliant insurers exiting the market, we estimated the number of enrollees that may be vulnerable to major coverage disruption given poor health status. RESULTS In 2009, using a PPACA-adjusted MLR definition, we estimated that 29% of insurer-state observations in the individual market would have MLRs below the 80% minimum, corresponding to 32% of total enrollment. Nine states would have at least one-half of their health insurers below the threshold. If insurers below the MLR threshold exit the market, major coverage disruption could occur for those in poor health; we estimated the range to be between 104,624 and 158,736 member-years. CONCLUSION The introduction of MLR regulation as part of the PPACA has the potential to significantly affect the functioning of the individual market for health insurance.

OBJECTIVE To illustrate the impact of moral hazard for estimating relative rates of underinsurance and to present an adjustment method to correct for this source of bias. DATA SOURCES/STUDY SETTING Secondary data from the 2005 Medical Expenditure Panel Survey (MEPS) are used in this study. We restrict attention to households that report having employer-sponsored insurance (ESI) for all members during the entire 2005 calendar year. STUDY DESIGN Individuals or households are often classified as underinsured if out-of-pocket spending on medical care relative to income exceeds some threshold. In this paper, we show that, without adjustment, this common threshold measure of underinsurance will underestimate the number with low levels of insurance coverage due to moral hazard. We propose an adjustment method and apply it to the specific case of estimating the difference in rates of underinsurance among small- versus large-firm workers with full-year ESI. DATA COLLECTION/EXTRACTION Data were abstracted from the MEPS website. All analyses were performed in Stata 9.2. PRINCIPAL FINDINGS Applying the adjustment, we find that the underinsurance rate of small-firm households increases by approximately 20 percent with the adjustment for moral hazard and the difference in underinsurance rates between large-firm and small-firm households widens substantially. CONCLUSIONS Adjusting for moral hazard makes a sizeable difference in the estimated prevalence of underinsurance using a threshold measure.

This study provides new estimates of demand for employer-sponsored health insurance, using the 1997-2001 linked Household Component-Insurance Component of the Medical Expenditure Panel Survey (MEPS). Our focus is on households' decisions to take up coverage through a worker's employer. We found a significant inverse relationship between the out-of-pocket premium and the probability of taking up coverage, with the price effect considerably larger when we used instrumental variables methods to account for endogenous out-of-pocket premiums. Additionally, workers in families with more children eligible for Medicaid were less likely to take up coverage.

Workers employed at small establishments are less likely to be offered health insurance than workers in larger establishments. They are also paid less and are less likely to be offered pensions, paid sick leave, and paid vacations. Using the Medical Expenditure Panel Survey, we examine the relationship between health insurance and other components of workers' compensation. We also propose an approach for identifying and prioritizing the reasons why workers in small establishments are less likely to be offered employer health insurance by comparing the provision of health insurance and how it changes with establishment size to the provision of these other fringe benefits and how they change with establishment size. We find that workers in larger establishments are not only more likely to be offered health insurance by their employer, but also are more likely to be offered retirement and paid vacation benefits. The results of our benefits comparison analysis suggest an important role for administrative costs as an obstacle to offering health insurance.

We examine the factors that lead employees to search for health plan quality information and the effect of such information on the decision to switch plans. Extending Hirshleifer and Riley's model [Hirshleifer, J., Riley, J.G., 1979. The analytics of uncertainty and information--an expositional survey. Journal of Economic Literature 17 (December (4)), 1375-1421] of the economics of information, we develop a two-equation model of quality information awareness and switching behavior. We estimate the model using data from a random sample of 651 single employees from 16 firms that are members of the Buyers Health Care Action Group, a health care purchasing coalition in the Minneapolis-St. Paul region. Our empirical results do not support either a link between quality information and switching behavior, or between perceived health plan satisfaction and switching. We do, however, find that switching is influenced by changes in premiums and whether an individual has an existing relationship with a health care provider.

More than half of all Americans receive health insurance coverage through an employer. The rising costs and escalating complexity of health insurance has led many employers to embark on extensive employee education campaigns. In 2002, 1,365 randomly selected employees from 16 Buyers Health Care Action Group firms in the Minneapolis region were surveyed to evaluate their awareness of employer-provided health plan quality information and the extent to which this information influences their enrollment decisions. The study found mixed evidence with respect to the value of employer communication. On one hand, employer communication does not significantly increase the probability that an employee responded correctly to the pharmacy benefit question posed in the survey. However, employer communication has a large effect on the awareness of quality information. How well those campaigns work, and by extension how well employees are informed about the health benefits decisions they make, is a key issue in health care today.

Using the 1996 Medical Expenditure Panel Survey, the authors investigate differences between households with two earners and those with a single earner in households' access to employer-based health insurance and the generosity of insurance options. They examine whether a household has an offer of coverage, whether a household holds coverage, and whether all household members are covered. They also explore whether two-earner households have more generous options as measured by the number and types of plans available, as well as contribution requirements. The authors find that having a second earner in the household dramatically improves both access to employer health insurance and the generosity of health plan choices, particularly for workers generally acknowledged to have little access, such as part-time workers and workers in small establishments.

The 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) approved tax-advantaged health savings accounts (HSAs) for certain high-deductible health insurance plans. We predict that MMA could lead to approximately 3.2 million HSA contracts among Americans ages 19-64 who are not students, not enrolled in public health insurance plans, and not eligible for group coverage as a dependent. We simulate the effect of several additional tax subsidies for HSAs. We predict that the Bush administration's refundable tax-credit proposal would double HSA take-up and reduce the number of uninsured people by 2.9 million, at an annual cost of $8.1 billion.

journals.sagepub.com/home/inq What do we already know about this topic? Adverse selection is a concern in the individual insurance market, and premiums have risen rapidly in recent years. How does your research contribute to the field? We show that state policy decisions-and in particular their decision to allow continued enrollment in Affordable Care Act noncompliant health insurance plans in the individual insurance market-are highly associated with health care costs of Affordable Care Act-compliant plans. What are your research's implications toward theory, practice, or policy? Current policy to permit the sale of noncompliant plans may have an impact on premiums of compliant plans. Abstract One of the Affordable Care Act's (ACA) signature reforms was creating centralized Health Insurance Marketplaces to offer comprehensive coverage in the form of comprehensive insurance complying with the ACA's coverage standards. Yet, even after the ACA's implementation, millions of people were covered through noncompliant plans, primarily in the form of continued enrollment in "grandmothered" and "grandfathered" plans that predated ACA's full implementation and were allowed under federal and state regulations. Newly proposed and enacted federal legislation may grow the noncompliant segment in future years, and the employment losses of 2020 may grow reliance on individual market coverage further. These factors make it important to understand how the noncompliant segment affects the compliant segment, including the Marketplaces. We show, first, that the noncompliant segment of the individual insurance market substantially outperformed the compliant segment, charging lower premiums but with vastly lower costs, suggesting that insurers have a strong incentive to enter the noncompliant segment. We show, next, that state's decisions to allow grandmothered plans is associated with stronger financial performance of the noncompliant market, but weaker performance of the compliant segment, as noncompliant plans attract lower-cost enrollees. This finding indicates important linkages between the noncompliant and compliant segments and highlights the role state policy can play in the individual insurance market. Taken together, our results point to substantial cream-skimming, with noncompliant plans enrolling the healthiest enrollees, resulting in higher average claims cost in the compliant segment.