Alabama: Round 1 - State-Level Field Network Study of the Implementation of the Affordable Care Act

This report is part of a series of 21 state and regional studies examining the rollout of the ACA. The national network -- with 36 states and 61 researchers -- is led by the Rockefeller Institute of Government, the public policy research arm of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania.More than 670,000 Alabamians under age sixty-five, or about 16 percent of the population, are uninsured. Most uninsured Alabamians are in working families (77 percent) where at least one person is employed either full time or part time. The largest total number and percentage of uninsured is aged nineteen to thirty and the uninsured are disproportionately people of color, although whites make up the majority of the uninsured population. The state insurance market is dominated by Blue Cross Blue Shield of Alabama (BCBSAL). In 2010, it had a 91 percent market share in the individual market with some 121,000 covered lives

Turmoil in the Health Insurance Marketplaces

SUMMARY: This brief explores the current volatility in the ACA’s Marketplaces and discusses key factors in their evolution over the past three years. As the law and Marketplaces stand now, continued proliferation of narrow network products and significant premium increases appear likely. The brief concludes with options for policymakers to address the turmoil in the Health Insurance Marketplaces

Five-State Study of ACA Marketplace Competition

The health insurance marketplaces created by the Affordable Care Act (ACA) were intended to broaden health insurance coverage by making it relatively easy for the uninsured, armed with income-related federal subsidies, to choose health plans that met their needs from an array of competing options. The further hope was that competition among health plans on the exchanges would lead to lower costs and higher value for consumers, because inefficient, low-value plans would lose out in the competitive market place. This study sought to understand the diverse experience in five states under the ACA in order to gain insights for improving competition in the private health insurance industry and the implementation of the ACA.In spring 2016, the insurance marketplaces had been operating for nearly three full years. There were numerous press stories of plans' decisions to enter or leave selected states or market areas within states and to narrow provider networks by including fewer choices among hospitals, medical specialists, and other providers. There were also beginning to be stories of insurer requests for significant premium increases. However, there was no clear understanding of how common these practices were, nor how and why practices differed across carriers, markets, and state regulatory settings.This project used the ACA Implementation Research Network to conduct field research in California, Michigan, Florida, North Carolina, and Texas. In each state, expert field researchers engaged directly with marketplace stakeholders, including insurance carriers, provider groups, state regulators, and consumer engagement organizations, to identify and understand their various decisions. This focus included an effort to understand why carriers choose to enter or exit markets and the barriers they faced, how provider networks were built, and how state regulatory decisions affected decision-making. Ultimately, it sought to find where and why certain markets are successful and competitive and how less competitive markets might be improved.The study of five states was not intended to provide statistically meaningful generalizations about the functioning of the marketplace exchanges. Rather, it was intended to accomplish two other objectives. First, the study was designed to generate hypotheses about the development and evolution of the exchanges that might be tested with "harder" data from all the exchanges. Second, it sought to describe the potentially idiosyncratic nature of the marketplaces in each of the five states. Political and economic circumstances may differ substantially across markets. Policymakers and market participants need to appreciate the nuances of different local settings if programs are to be successful. What works in Michigan may not work in Texas and vice versa. Field research of this sort can give researchers and policymakers insight into how idiosyncratic local factors matter in practice.In brief, our five states had four years of experience in the open enrollment periods from 2014 through 2017. The states array themselves in a continuum of apparent success in enhancing and maintaining competition among insurers. California and Michigan appear to have had success in nurturing insurer competition, in at least the urban areas of their states. Florida, North Carolina, and Texas were less successful. This divergence is recent, however. As recently as the 2015 and 2016 open enrollment periods, all of the states had what appeared to be promising, if not always robust, insurance competition. Large changes occurred in the run-up to the 2017 open enrollment period

HDAC3-Dependent Epigenetic Pathway Controls Lung Alveolar Epithelial Cell Remodeling and Spreading via miR-17-92 and TGF-β Signaling Regulation

SummaryThe terminal stages of pulmonary development, called sacculation and alveologenesis, involve both differentiation of distal lung endoderm progenitors and extensive cellular remodeling of the resultant epithelial lineages. These processes are coupled with dramatic expansion of distal airspace and surface area. Despite the importance of these late developmental processes and their relation to neonatal respiratory diseases, little is understood about the molecular and cellular pathways critical for their successful completion. We show that a histone deacetylase 3 (Hdac3)-mediated epigenetic pathway is critical for the proper remodeling and expansion of the distal lung saccules into primitive alveoli. Loss of Hdac3 in the developing lung epithelium leads to a reduction of alveolar type 1 cell spreading and a disruption of lung sacculation. Hdac3 represses miR-17-92 expression, a microRNA cluster that regulates transforming growth factor β (TGF-β) signaling. De-repression of miR-17-92 in Hdac3-deficient lung epithelium results in decreased TGF-β signaling activity. Importantly, inhibition of TGF-β signaling and overexpression of miR-17-92 can phenocopy the defects observed in Hdac3 null lungs. Conversely, loss of miR-17-92 expression rescues many of the defects caused by loss of Hdac3 in the lung. These studies reveal an intricate epigenetic pathway where Hdac3 is required to repress miR-17-92 expression to allow for proper TGF-β signaling during lung sacculation

The Cellular and Physiological Basis for Lung Repair and Regeneration: Past, Present, and Future.

The respiratory system, which includes the trachea, airways, and distal alveoli, is a complex multi-cellular organ that intimately links with the cardiovascular system to accomplish gas exchange. In this review and as members of the NIH/NHLBI-supported Progenitor Cell Translational Consortium, we discuss key aspects of lung repair and regeneration. We focus on the cellular compositions within functional niches, cell-cell signaling in homeostatic health, the responses to injury, and new methods to study lung repair and regeneration. We also provide future directions for an improved understanding of the cell biology of the respiratory system, as well as new therapeutic avenues

Assessing the Quality Measure for Follow-up Care After Children’s Psychiatric Hospitalizations

OBJECTIVES: Medicaid and Children’s Health Insurance Program plans publicly report quality measures, including follow-up care after psychiatric hospitalization. We aimed to understand failure to meet this measure, including measurement definitions and enrollee characteristics, while investigating how follow-up affects subsequent psychiatric hospitalizations and emergency department (ED) visits. METHODS: Administrative data representing Alabama’s Children’s Health Insurance Program from 2013 to 2016 were used to identify qualifying psychiatric hospitalizations and follow-up care with a mental health provider within 7 to 30 days of discharge. Using relaxed measure definitions, follow-up care was extended to include visits at 45 to 60 days and visits to a primary care provider. Logit regressions estimated enrollee characteristics associated with follow-up care and, separately, the likelihood of subsequent psychiatric hospitalizations and/or ED visits within 30, 60, and 120 days. RESULTS: We observed 1072 psychiatric hospitalizations during the study period. Of these, 356 (33.2%) received follow-up within 7 days and 566 (52.8%) received it within 30 days. Relaxed measure definitions captured minimal additional follow-up visits. The likelihood of follow-up was lower for both 7 days (−18 percentage points; 95% confidence interval [CI] −26 to −10 percentage points) and 30 days (−26 percentage points; 95% CI −35 to −17 percentage points) regarding hospitalization stays of ≥8 days. Meeting the measure reduced the likelihood of subsequent psychiatric hospitalizations within 60 days by 3 percentage points (95% CI −6 to −1 percentage point). CONCLUSIONS: Among children, receipt of timely follow-up care after a psychiatric hospitalization is low and not sensitive to measurement definitions. Follow-up care may reduce the need for future psychiatric hospitalizations and/or ED visits

Adverse Selection in the Children’s Health Insurance Program

This study investigates whether new enrollees in the Alabama Children’s Health Insurance Program have different claims experience from renewing enrollees who do not have a lapse in coverage and from continuing enrollees. The analysis compared health services utilization in the first month of enrollment for new enrollees (who had not been in the program for at least 12 months) with utilization among continuing enrollees. A second analysis compared first-month utilization of those who renew immediately with those who waited at least 2 months to renew. A 2-part model estimated the probability of usage and then the extent of usage conditional on any utilization. Claims data for 826 866 child-years over the period from 1999 to 2012 were used. New enrollees annually constituted a stable 40% share of participants. Among those enrolled in the program, 13.5% renewed on time and 86.5% of enrollees were late to renew their enrollment. In the multivariate 2-part models, controlling for age, gender, race, income eligibility category, and year, new enrollees had overall first-month claims experience that was nearly $29 less than continuing enrollees. This was driven by lower ambulatory use. Late renewals had overall first-month claims experience that was$10 less than immediate renewals. However, controlling for the presence of chronic health conditions, there was no statistically meaningful difference in the first-month claims experience of late and early renewals. Thus, differences in claims experience between new and continuing enrollees and between early and late renewals are small, with greater spending found among continuing and early renewing participants. Higher claims experience by early renewals is attributable to having chronic health conditions