During the 2019 open enrollment period in California's Affordable Care Act (ACA) Marketplace, we used a randomized intervention to examine the effects of email and postal messages on choice errors, ...where low-income households enroll in gold or platinum plans although they are eligible for cost-sharing reduction (CSR) silver plans with lower premiums and higher actuarial values. Relative to the control group, assignment to the email-only treatment increased plan switching to CSR silver plans by 2 percentage points (an 11 percent increase), and assignment to the mail-plus-email treatment increased plan switching to CSR silver plans by 3.9 percentage points (a 22 percent increase). The mail-plus-email treatment significantly increased plan switching across all subpopulations in which choice errors were made. Consumers who switched out of a plan chosen in error saved an average of $84 per month in premiums and $56 per month in reduced out-of-pocket expenses. Our results indicate that low-cost nudges can help low-income enrollees obtain more generous coverage at a lower price and that the combination of email and postal messages is more effective at increasing plan switching than email alone to rectify choice errors.
We experimentally varied information mailed to 87,000 households in California’s health insurance marketplace to study the role of frictions in insurance take-up. Reminders about the enrollment ...deadline raised enrollment by 1.3 pp (16 percent) in this typically low take-up population. Heterogeneous effects of personalized subsidy information indicate misperceptions about program benefits. Consistent with an adverse selection model with frictional enrollment costs, the intervention lowered average spending risk by 5.1 percent, implying that marginal respondents were 37 percent less costly than inframarginal consumers. We observe the largest positive selection among low income consumers, who exhibit the largest frictions in enrollment. Finally, we estimate the implied value of the letter intervention to be $25 to $53 per month in subsidy dollars. These results suggest that frictions may partially explain low take-up for marketplace insurance, and that interventions reducing them can improve enrollment and market risk in exchanges.
During the 2022 open enrollment period in California's Affordable Care Act Marketplace, we tested two interventions designed to reduce choice errors among low-income households enrolled in bronze ...plans that were eligible for zero-premium cost-sharing reduction (CSR) silver plans with more generous benefits. A randomized controlled trial nudge intervention used letter and email reminders to encourage consumers to switch plans, and a quasi-experimental crosswalk intervention automatically enrolled eligible households from bronze plans into zero-premium CSR silver plans with the same insurers and provider networks. The nudge intervention led to a statistically significant 2.3-percentage-point (26 percent) increase in CSR silver plan take-up relative to the control group, but nearly 90 percent of households remained in nonsilver plans. The automatic crosswalk intervention resulted in an 83.0-percentage-point (822 percent) increase in CSR silver plan take-up compared with the control group, with more than 90 percent of households enrolled in CSR silver plans. Our findings can inform health policy debates on the relative effectiveness of different approaches to reducing choice errors among low-income households in the Affordable Care Act Marketplaces.
More than one million low-income uninsured people are eligible for zero-premium cost-sharing reduction (CSR) silver plans through the Affordable Care Act (ACA) Marketplaces. However, many are not ...aware of these options, and Marketplaces are uncertain about what types of informational messages will increase take-up. In 2021 and 2022, before and after the introduction of zero-premium plans in Covered California, California's individual ACA Marketplace, we conducted two randomized controlled trials among low-income households that submitted an application and were found eligible for $1 per month or zero-premium coverage but were not yet enrolled. We tested the effect of personalized letters and emails that informed households that they were eligible for a $1 per month or zero-premium CSR silver plan. Across both settings, low-cost personalized outreach increased rates of ACA enrollment, CSR silver plan take-up, and $1 per month or zero-premium CSR silver plan take-up. But even with free or nearly free coverage options, absolute rates of enrollment remained low, suggesting that more resource-intensive efforts are needed to help prospective enrollees overcome nonprice barriers.
Individual health insurance marketplaces established through the Affordable Care Act of 2010 (ACA) fill a critical gap for those who lack other coverage options. The high degree of coverage turnover, ...or churn, has raised concerns about affordability and strategic behavior on the part of individuals to sign up only when they need care.
To assess the role of California's ACA marketplaces in the broader health care landscape by understanding enrollment tenure and churn.
This cross-sectional study analyzed survey data from a representative, probability-based sample of enrollees in California's ACA marketplace, Covered California, collected immediately after the open enrollment periods in 2018, 2019, and 2021. Administrative data from Covered California from January 1, 2014, to December 31, 2021, were used to analyze marketplace tenure. Survey data included 9571 heads of households aged 18 to 64 years who were newly enrolled or had recently terminated their plan, directly drawn from Covered California's administrative records. Administrative data included individuals up to age 65 years who enrolled in the marketplace during 2014 to 2021.
New enrollment in or termination from health care coverage through California's ACA marketplace.
Enrollment tenure in California's ACA marketplace, sources of coverage prior to enrolling and after terminating coverage, and demographic or plan characteristics associated with the decision to go uninsured.
Median (IQR) length of coverage among 5.4 million enrollees (mean SD age, 38 16 years; 17% Asian American/Native Hawaiian or other Pacific Islander, 2.5% Black or African American, 23% Latino response options were Hispanic, Spanish, or Latino origin, 29% White, 7.5% categorized as other including American Indian/Alaskan Native, multiple races, and other, and 21% of unknown race or ethnicity) was 14 (6-35) months, and 41% to 46% of enrollees disenrolled within 1 year, with substantial variation by subgroups. Despite this churn, only 14% (95% CI, 12%-15%) of 6474 terminating members surveyed across 3 years (2018, 2019, and 2021) reported being uninsured after leaving the marketplace, with the rest moving to job-based coverage or Medicaid. Most of those surveyed (mean SE percentage, 56% 0.016 individuals) reported having had employer-sponsored insurance or Medicaid prior to enrolling in the marketplace. Among subsidized renewal candidates, Latino candidates were 1.5 percentage points (95% CI, 0.8-2.3 percentage points) more likely to go uninsured compared with White candidates, and those with no expected physician visits in the coming year were 4.8 percentage points (95% CI, 2.4-7.2 percentage points) more likely to go uninsured vs those who expected physician visits.
The results of this cross-sectional study of coverage churn found that ACA marketplaces served 2 distinct types of individuals, long-term enrollees but, more often, individuals with short-term-coverage needs due to a change in eligibility for other insurance. These results suggest that marketplaces are smoothing coverage disruptions and that policies to reduce gaps in coverage should be designed with this in mind.
This randomized clinical trial examines the effect of email reminders, personalized telephone outreach, and a combination of both on Affordable Care Act enrollment among households who recently lost ...Medicaid and became eligible for subsidized marketplace coverage in 2017 in California.
Brain metastases occur frequently in melanoma patients with advanced disease whereby the prognosis is dismal. The underlying mechanisms of melanoma brain metastasis development are not well ...understood. Identification of molecular determinants regulating melanoma brain metastasis would advance the development of prevention and therapy strategies for this disease. Gene expression profiles of cutaneous and brain‐metastasizing melanoma variants from three xenograft tumor models established in our laboratory revealed that expression of tight junction component CLDN1 was lower in the brain‐metastasizing variants than in cutaneous variants from the same melanoma. The objective of our study was to determine the significance of CLDN1 downregulation/loss in metastatic melanoma and its role in melanoma brain metastasis. An immunohistochemical analysis of human cells of the melanocyte lineage indicated a significant CLDN1 downregulation in metastatic melanomas. Transduction of melanoma brain metastatic cells expressing low levels of CLDN1 with a CLDN1 retrovirus suppressed their metastatic phenotype. CLDN1‐overexpressing melanoma cells expressed a lower ability to migrate and adhere to extracellular matrix, reduced tumor aggressiveness in nude mice and, most importantly, eliminated the formation of micrometastases in the brain. In sharp contrast, the ability of the CLDN1‐overexpressing cells to form lung micrometastases was not impaired. CLDN1‐mediated interactions between these cells and brain endothelial cells constitute the mechanism underlying these results. Taken together, we demonstrated that downregulation or loss of CLDN1 supports the formation of melanoma brain metastasis, and that CLDN1 expression could be a useful prognostic predictor for melanoma patients with a high risk of brain metastasis.
What's new?
Melanoma often metastasizes to the brain, but if researchers could find out how it does so, perhaps they could prevent it. Cells poised to metastasize often reveal themselves by molecular clues, and indeed, melanoma cells likely to infiltrate the brain express less of the tight‐junction protein CLDN1 than other melanoma cells. In this study, the authors showed that when melanoma cells express extra CLDN1, they could not form micro‐metastases in the brain – though their ability to metastasize to the lungs was not impaired. Thus, CLDN1 expression could help predict the likelihood of brain metastasis, and targeting cells expressing low levels of the protein could help prevent or treat this deadly complication.
Acute myocardial infarction during pregnancy is considered to be associated with approximately 50% mortality of both mother and fetus. However, there are not enough data regarding the role of acute ...myocardial ischemia. We present a 36‐year‐old, pregnant, white female who was admitted twice at 18 and 20 weeks of gestation with acute myocardial ischemia. Cardiac catheterization revealed 70–80% stenosis of the mid left anterior descending artery (LAD) with normal antegrade flow and very good retrograde filling of the LAD from distal collaterals of the right coronary artery. Therefore, due to angiographic suggestion of protected LAD territory, we recommended medical therapy and scheduled a vaginal delivery that was successfully completed without cardiovascular complications. A stress thallium test performed 6 months later was normal, supporting our clinical judgment. In conclusion, every case of a pregnant woman with coronary insufficiency should be treated according to individual coronary anatomy and blood supply to the territory of the diseased artery, and should not be based on the old data in the literature. The decision for revascularization prior to delivery versus medical therapy, or Caesarean section versus natural delivery, should be made by a team of a cardiologist and an obstetrician.
Primary aorto-enteric fistulae are rare. Preoperative diagnosis is important but is difficult and cannot usually be confirmed by upper gastrointestinal series, aortography and endoscopy. Computed ...tomography demonstrating an abdominal aortic aneurysm with air bubbles in its wall and "soft tissue" mass posteriorly should raise the possibility of penetration of the aneurysm into the lumen of the bowel and related consequences (hematoma, sepsis, infected operating field).
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