Mental illnesses affect roughly 20 percent of the US population. Like other health conditions, mental illnesses impose costs on individuals; they also generate costs that extend to family members and ...the larger society. Care for mental illnesses has evolved quite differently from the rest of health care sector. While medical care in general has seen major advances in the technology of treatment this has not been the case to the same extent for the treatment of mental illnesses. Relative to other illnesses, the cost of care for mental illnesses has grown more slowly and the social cost of illness has grown more rapidly. In this essay we offer evidence about the forces underpinning these patterns and emphasize the challenges stemming from the heterogeneity of mental illnesses. We examine institutions and rationing mechanisms that affect the ability to make appropriate matches between clinical problems and treatments. We conclude with a review of implications for policy and economic research.
The Affordable Care Act was designed to provide financial protection to Americans in their use of the health care system. This required addressing two intertwined problems: cost barriers to accessing ...coverage and care, and barriers to comprehensive risk protection provided by insurance. We reviewed the evidence on whether the law was effective in achieving these goals. We found that the Affordable Care Act generated substantial, widespread improvements in protecting Americans against the financial risks of illness. The coverage expansions reduced uninsurance rates, especially relative to earlier forecasts; improved access to care; and lowered out-of-pocket spending. The insurance market reforms also made it easier for people to get and stay enrolled in coverage and ensured that those who were insured had true financial risk protection. But subsequent court decisions and congressional and executive branch actions have left millions uninsured and allowed the risk of inadequate insurance to resurface.
Background
Robotic prostatectomy is a costly new technology, but the costs may be offset by changes in treatment patterns. The net effect of this technology on Medicaid spending has not been ...assessed.
Objective
To identify the association of the local availability of robotic surgical technology with choice of initial treatment for prostate cancer and total prostate cancer–related treatment costs.
Design and Participants
This cohort study used New York State Medicaid data to examine the experience of 9564 Medicaid beneficiaries 40–64 years old who received a prostate biopsy between 2008 and 2017 and were diagnosed with prostate cancer. The local availability of robotic surgical technology was measured as distance from zip code centroids of patient’s residence to the nearest hospital with a robot and the annual number of robotic prostatectomies performed in the Hospital Referral Region.
Main Measures
Multivariate linear models were used to relate regional access to robots to the choice of initial therapy and prostate cancer treatment costs during the year after diagnosis.
Key Results
The mean age of the sample of 9564 men was 58 years; 30% of the sample were White, 26% were Black, and 22% were Hispanic. Doubling the distance to the nearest hospital with a robot was associated with a reduction in robotic surgery rates of 3.7 percentage points and an increase in the rate of use of radiation therapy of 5.2 percentage points. Increasing the annual number of robotic surgeries performed in a region by 10 was associated with a decrease in the probability of undergoing radiation therapy of 0.6 percentage point and a $434 reduction in total prostate cancer–related costs per Medicaid patient.
Conclusions
A full accounting of the costs of a new technology will depend on when it is used and the payment rate for its use relative to payment rates for substitutes.
To evaluate the effects of a comprehensive traffic safety policy-New York City's (NYC's) 2014 Vision Zero-on the health of Medicaid enrollees.
We conducted difference-in-differences analyses using ...individual-level New York Medicaid data to measure traffic injuries and expenditures from 2009 to 2021, comparing NYC to surrounding counties without traffic reforms (n = 65 585 568 person-years).
After Vision Zero, injury rates among NYC Medicaid enrollees diverged from those of surrounding counties, with a net impact of 77.5 fewer injuries per 100 000 person-years annually (95% confidence interval = -97.4, -57.6). We observed marked reductions in severe injuries (brain injury, hospitalizations) and savings of $90.8 million in Medicaid expenditures over the first 5 years. Effects were largest among Black residents. Impacts were reversed during the COVID-19 period.
Vision Zero resulted in substantial protection for socioeconomically disadvantaged populations known to face heightened risk of injury, but the policy's effectiveness decreased during the pandemic period.
Many cities have recently launched Vision Zero policies and others plan to do so. This research adds to the evidence on how and in what circumstances comprehensive traffic policies protect public health. (
. 2024;114(6):633-641. https://doi.org/10.2105/AJPH.2024.307617).
For individuals with serious mental illness, work can play an important role in improving quality of life and community integration. Since the 1960s, demand has shifted away from routine cognitive ...(e.g., clerical work) and manual skills (warehouse picking and packing) toward nonroutine analytical (computer coding), interpersonal (nursing), and manual skills (home health attendant). This study aimed to determine whether individuals with serious mental illness are likely to hold the types of jobs that are in decline and to assess their ability to compete for the types of jobs that have been in increased demand.
Using data from the National Health Interview Survey and the Occupational Information Network database on occupational skills (N=387,240 person-year responses), this study explored changes in patterns of employment from 1997 to 2017 for people with mental illnesses.
Individuals with any mental health condition experienced a 10.9 percentage point decline in employment in jobs requiring routine cognitive or any manual skills. Much of this decline was offset by an increase in employment in jobs involving nonroutine cognitive skills. However, individuals with serious psychological distress experienced a 7.9 percentage point decline in employment in jobs requiring routine cognitive or any manual skills, and about 75% of this decline coincided with reduced levels of employment rather than a shift toward employment in nonroutine cognitive jobs. These patterns were more striking among men.
Likely directions for interventions include renewed efforts at workplace accommodations, greater investment in evidence-based return-to-work programs, and efforts to popularize early intervention programs.
Policy responses to the March 31, 2023, expiration of the Medicaid continuous coverage provision need to consider the difference between self-reported Medicaid participation on government surveys and ...administrative records of Medicaid enrollment. The difference between the two is known as the "Medicaid undercount." The size of the undercount increased substantially after the continuous coverage provision took effect in March 2020. Using longitudinal data from the Current Population Survey, we examined this change. We found that assuming that all beneficiaries who ever reported enrolling in Medicaid during the COVID-19 pandemic public health emergency remained enrolled through 2022 (as required by the continuous coverage provision) eliminated the worsening of the undercount. We estimated that nearly half of the 5.9 million people who we projected were likely to become uninsured after the provision expired, or "unwound," already reported that they were uninsured in the 2022 Current Population Survey. This finding suggests that the impact of ending the continuous coverage provision on the estimated uninsurance rate, based on self-reported survey data, may have been smaller than anticipated. It also means that efforts to address Medicaid unwinding should include people who likely remain eligible for Medicaid but believe that they are already uninsured.
The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient ...surgical care, particularly among underserved populations, remains unknown.
To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care.
This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019.
State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act.
Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage.
A total of 207 176 patients (106 395 women 51.35% and 100 781 men 48.65%; mean SD age, 45.7 12.4 years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states.
Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.
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