Sue Ducat
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Health Affairs’ January Issue

Bethesda, MD - On the eve of the expected debate over the fate of the Affordable Care Act (ACA), the January issue of Health Affairs, a variety issue, contains a number of studies that examine how the law has worked thus far. “The relative youth of ‘Obamacare’ limits what can be said about its potential long-term effects,” Health Affairs’ editor-in-chief, Alan Weil, observes in his editor’s letter. “It is more important than ever to have a solid base of evidence regarding the law’s accomplishments and shortcomings.”

In California, premium increases are lower than reported.
During the recent presidential election, the announced 22 percent increase in Marketplace premiums for 2017 received a great deal of media attention. Jon Gabel at NORC and coauthors examined publicly available 2014-16 enrollment data for California’s state exchange, Covered California. They found that the average purchased price for all plans was 11.6 percent less than the average offered price in 2014, and that this difference widened each year. The authors attributed much of this discrepancy to more enrollees buying lower-cost bronze and silver plans, and fewer buying gold and platinum plans—which had the largest premium increases in those years. They conclude that if consumers are given clear options, and aren’t overwhelmed by too many choices, they will buy lower-premium products and thus successfully moderate any cost growth. That conclusion is supported by the data from Covered California, the only state to make its Marketplace plan enrollment data publicly available. 

A related study in the issue: 

Market share affects insurer and provider negotiated prices.
Understanding the extent to which large insurers are able to negotiate lower prices from providers is essential for determining how insurer mergers may affect health care costs. To evaluate the association between insurer market power and health care prices, Eric Roberts and coauthors from Harvard Medical School analyzed over 15 million 2014 claims from a large, multipayer database of commercial health care claims for outpatient physician services. Their results indicate that insurers with substantial market shares pay rates that are 21 percent lower, on average, than the rates paid to the same providers by insurers with small market shares. Large insurers’ ability to negotiate lower prices was particularly evident in payments to large provider groups, suggesting that insurer mergers may help control price increases driven by provider consolidation. However, the authors stress that policy makers will need to develop and enforce mechanisms that ensure consumers benefit from any further insurer consolidation.

DATAWATCH: Many of the newly insured in 2014 were long-term uninsured.
One of the critical questions about ACA Marketplace enrollment has been whether the gains in insurance coverage come from those who had briefly lacked coverage or from the long-term uninsured. To answer that question, Sandra Decker and Brandy Lipton, both of the Agency for Healthcare Research and Quality (AHRQ), used data for 2013–14 from the National Health Interview Survey (NHIS), focusing on nonelderly adults most likely to be affected by ACA policy changes. According to the authors’ analysis, people who had been uninsured for more than three years accounted for more than half of the overall gain in coverage in 2014 (see the exhibit below). The authors note that this group of newly insured Americans might not be in the habit of using health care and recommend further studying the group’s health care utilization and ability to access appropriate providers.

Cancer care: Declining rates of prostate cancer treatment among older men.
The indolent nature of many prostate cancers has brought about less aggressive screening for and treatment of this disease. To understand the population-level impact on this course of action, Tudor Borza and coauthors from the University of Michigan Health System used national Medicare data for the period 2007–12 to assess treatment rates among men with newly diagnosed prostate cancer. The authors found that during that period, treatment rates for the overall population declined by 42 percent, while rates among men diagnosed with prostate cancer fell by only 8 percent. The authors conclude that the decreasing rates of screening and diagnosis, as opposed to changes in practice patterns by specialists, caused the decline in population-based treatment rates. This study is believed to be the first population-level analysis of prostate cancer treatment rates in recent years, a time that witnessed changes to both prostate-specific antigen (PSA) screening guidelines and treatment protocols.

Also of interest in the January issue:

Global health: Brazil’s primary health care expansion.
The role of governance in improving health is widely recognized as necessary, but is difficult to tie to actual outcomes. Thomas Hone, of Imperial College London, and coauthors examine whether expansion of the Brazilian Estratégia de Saúde da Família (ESF; family health strategy), a community-based primary care program, reduced amenable mortality (mortality avoidable with timely and effective health care) and whether this association varied by municipal health governance. Using municipality data from Brazil for the years 2000–12, the authors found that while socioeconomic characteristics improved over the time period, increased primary care coverage was associated with reductions in rates of amenable mortality. They also measured the strength of local health governance within each municipality and demonstrated that municipalities with the highest governance scores had the largest reductions in mortality. According to the authors’ findings, expanding the provision of primary health care can have a substantial impact on mortality rates, but strong local governance is essential to the implementation of effective services and the achievement of better health outcomes in terms of reduced amenable mortality rates.

Also of global interest:

NOTE: Check out Health Affairs’ newest web hub: From Obamacare to Trumpcare. Key health policy questions are explored for the Affordable Care Act (ACA), Medicare, Medicaid, and payment reform.

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print and online, with additional Web First papers and health policy briefs published regularly at You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download monthly Narrative Matters podcasts. Tap into Health Affairs content with the iPad app.