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

Why the fair innings argument is not persuasive

The fair innings argument (FIA) is frequently put forward as a justification for denying elderly patients treatment when they are in competition with younger patients and resources are scarce. In this paper I will examine some arguments that are used to support the FIA. My conclusion will be that they do not stand up to scrutiny and therefore, the FIA should not be used to justify the denial of treatment to elderly patients, or to support rationing of health care by age. There are six issues arising out of the FIA which are to be addressed. First, the implication that there is such a thing as a fair share of life. Second, whether it makes sense to talk of a fair share of resources in the context of health care and the FIA. Third, that 'fairness' is usually only mentioned with regard to the length of a person's life, and not to any other aspect of it. Fourth, if it is sensible to discuss the merits of the FIA without taking account of the 'all other things being equal' argument. Fifth, the difference between what is unfair and what is unfortunate. Finally, that it is tragic if a young person dies, but only unfortunate if an elderly person does

A connectome and analysis of the adult Drosophila central brain.

The neural circuits responsible for animal behavior remain largely unknown. We summarize new methods and present the circuitry of a large fraction of the brain of the fruit fly Drosophila melanogaster. Improved methods include new procedures to prepare, image, align, segment, find synapses in, and proofread such large data sets. We define cell types, refine computational compartments, and provide an exhaustive atlas of cell examples and types, many of them novel. We provide detailed circuits consisting of neurons and their chemical synapses for most of the central brain. We make the data public and simplify access, reducing the effort needed to answer circuit questions, and provide procedures linking the neurons defined by our analysis with genetic reagents. Biologically, we examine distributions of connection strengths, neural motifs on different scales, electrical consequences of compartmentalization, and evidence that maximizing packing density is an important criterion in the evolution of the fly's brain

Meta-analysis of pre-clinical studies of early decompression in acute spinal cord injury:a battle of time and pressure

The use of early decompression in the management of acute spinal cord injury (SCI) remains contentious despite many pre-clinical studies demonstrating benefits and a small number of supportive clinical studies. Although the pre-clinical literature favours the concept of early decompression, translation is hindered by uncertainties regarding overall treatment efficacy and timing of decompression.We performed meta-analysis to examine the pre-clinical literature on acute decompression of the injured spinal cord. Three databases were utilised; PubMed, ISI Web of Science and Embase. Our inclusion criteria consisted of (i) the reporting of efficacy of decompression at various time intervals (ii) number of animals and (iii) the mean outcome and variance in each group. Random effects meta-analysis was used and the impact of study design characteristics assessed with meta-regression.Overall, decompression improved behavioural outcome by 35.1% (95%CI 27.4-42.8; I(2)=94%, p<0.001). Measures to minimise bias were not routinely reported with blinding associated with a smaller but still significant benefit. Publication bias likely also contributed to an overestimation of efficacy. Meta-regression demonstrated a number of factors affecting outcome, notably compressive pressure and duration (adjusted r(2)=0.204, p<0.002), with increased pressure and longer durations of compression associated with smaller treatment effects. Plotting the compressive pressure against the duration of compression resulting in paraplegia in individual studies revealed a power law relationship; high compressive forces quickly resulted in paraplegia, while low compressive forces accompanying canal narrowing resulted in paresis over many hours.These data suggest early decompression improves neurobehavioural deficits in animal models of SCI. Although much of the literature had limited internal validity, benefit was maintained across high quality studies. The close relationship of compressive pressure to the rate of development of severe neurological injury suggests that pressure local to the site of injury might be a useful parameter determining the urgency of decompression

Electrodiagnostic Grade and Carpal Tunnel Release Outcomes: A Prospective Analysis

Purpose: The value of electrodiagnostic (EDX) study grades as a prognostic indicator of clinical results after carpal tunnel release (CTR) remains controversial. In this study, we tested the primary null hypothesis that symptom relief after CTR would not differ based on EDX grade. Secondarily, we evaluated the degree of symptomatic and functional postoperative improvement relative to preoperative EDX grade. Methods: We prospectively evaluated 199 consecutive patients with 256 hands after CTR confirmed with EDX. Data were collected before surgery and patients were observed at 2 weeks and 3 months after surgery. There were 20 hands with mild, 126 with moderate, and 110 with severe involvement in the preoperative EDX. Demographic, EDX grade (mild, moderate, or severe); surgical parameters; Quick–Disabilities of the Arm, Shoulder, and Hand questionnaire; symptom severity scale, functional status scale, pain catastrophizing scale, and visual analog scale data were collected and analyzed. Results: There was significant improvement in Quick–Disabilities of the Arm, Shoulder, and Hand, symptom severity scale, and functional status scale scores from the preoperative to 2-week and 3-month postoperative visits in all categories of EDX grade. There was no significant difference in the extent of recovery by the 2-week and 3-month visits relative to EDX grade. Catastrophic thinking did not have a significant effect on any of the 3 groups. Pain decreased dramatically at 2 weeks after surgery but there was no additional significant difference in visual analog scale scores between the 2-week and 3-month postoperative visits. Postoperative pain improvement occurred regardless of EDX grade. There were no major complications or reoperations in any group. Conclusions: Carpal tunnel release demonstrated consistently significant improvement in outcomes regardless of EDX grade at initial and final follow-up. The extent of postoperative improvement after CTR overall was also not statistically different between groups with differing EDX severity. Older patients with severe CTS achieved more modest gains. Type of study/level of evidence: Prognostic II