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    1 Comment for this article
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    The Importance of Considering Quality and Choice of Health Care in Addition to Cost
    Richard Fleming, PhD, MD, JD; Matthew R Fleming, BS, NRP; Tapan K Chaudhuri, MD | FHHI-OI-Camelot; Eastern Virginia Medical School
    The study by Tipirneni, et al is an interesting look at the out of pocket costs, for care reported, for individuals covered by the Affordable Care Act (ACA) Medicaid expansion program. It is not, however, a study of the quality of care provided or the choice of care provided to these individuals.

    There are several reasons why out of pocket expenses can decrease. The first would be an actual improved quality of care - with the patient’s office and hospital visits being covered in addition to the costs of testing, prescription drugs, and other related health care costs.
    That, of course, is the inference being made by this study and a Medicare-for-All approach. It is not, however what is shown here.

    There are unfortunately multiple other reasons – which are not covered in this study – which can also explain why reductions in out of pocket costs can occur. Including, inter alia:

    1. Decisions to not seek medical care because the provider the patient is required to see is different from the provider they would choose to see, if they had another insurance.

    2. Decisions by patients to not seek medical assistance due to costs and their expectations that they will not receive the same quality of care provided to people with private insurance, expectations that are at least to some extent founded by what is and isn’t covered under this government-run healthcare program.

    3. Decisions about whether the patients can afford to fill prescriptions under the ACA Medicaid expansion, given the continued run away prescription drug prices resulting from an uncontrolled BigPharma.

    4. Decisions not to undergo medical testing due to lack of coverage for such tests.

    5. Decisions to avoid hospital admission due to failure of coverage of such admissions or the requirement that they most go to a hospital different from the one they would choose to go to if they had private insurance.

    While this is by no means an all-encompassing list, it does demonstrate the tiered - caste system - level of medical care resulting from a government-run health care system.

    This paper by Tipirneni, et al, points out the limitations with the current ACA. It would be nice to think ACA provided better health care for people as a result of being part of a government-run health care program – unfortunately it does not.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    Health Policy
    February 7, 2020

    Health Insurance Affordability Concerns and Health Care Avoidance Among US Adults Approaching Retirement

    Author Affiliations
    • 1Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 2Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
    • 3Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor
    • 4VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
    • 5Department of Pediatrics, University of Michigan, Ann Arbor
    • 6Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
    JAMA Netw Open. 2020;3(2):e1920647. doi:10.1001/jamanetworkopen.2019.20647
    Key Points español 中文 (chinese)

    Question  Do US adults have concerns about health insurance during retirement, and if so, are these concerns associated with avoidance of medical care?

    Findings  In this nationally representative survey study of 1028 US adults aged 50 to 64 years, 44.6% had low confidence in being able to afford health insurance during retirement, and 67.7% were concerned about potential changes to health insurance associated with changes in federal policies. Individuals with low confidence in health insurance affordability were more likely than those with higher confidence to avoid medical care and medications.

    Meaning  Policy solutions are needed to help patients better understand coverage options and navigate health care during the critical transition period before Medicare eligibility.

    Abstract

    Importance  As US adults approach Medicare eligibility at age 65 years, they face important decisions about health care and employment. Recent legislative, regulatory, and legal challenges to the Affordable Care Act may add new uncertainties to this decision-making.

    Objective  To understand adults’ perspectives on health insurance, health care, and employment near retirement.

    Design, Setting, and Participants  In October 2018, a cross-sectional online survey study of community-dwelling US adults aged 50 to 64 years was conducted with Ipsos KnowledgePanel, a nationally representative internet survey panel (completion rate, 62%). The initial data analysis was conducted from November 2018 to March 2019, and additional analyses were conducted in November 2019.

    Main Outcomes and Measures  Confidence in affording health insurance, keeping a job or delaying retirement to have employer-sponsored health insurance, concerns about potential changes to health insurance associated with changes in federal policies, and avoidance of medical care or medication because of cost.

    Results  Among 1028 respondents aged 50 to 64 years (mean [SD] age, 57.0 [4.2] years), 51.8% (95% CI, 48.6%-55.0%) were female, 40.4% (95% CI, 37.2%-43.7%) had a high school education or less, 65.2% (95% CI, 62.1%-68.3%) were employed, and 34.8% (95% CI, 31.7%-37.9%) were retired or not working. Approximately one-fourth of respondents (27.4%; 95% CI, 24.6%-30.4%) had little to no confidence in being able to afford health insurance over the next year, and nearly one-half (44.6%; 95% CI, 41.4%-47.8%) had little to no confidence in their ability to afford health insurance when they retire; 14.1% (95% CI, 12.0%-16.5%) reported keeping a job and 11.4% (95% CI, 9.6%-13.6%) reported delaying or considering delaying retirement to have employer-sponsored health insurance. Most respondents (67.7%; 95% CI, 64.6%-70.6%) were very or somewhat concerned about potential changes to their health insurance associated with changes in federal policies. In the past year, 13.2% (95% CI, 11.2%-15.5%) of respondents did not get medical care and 11.9% (95% CI, 9.9%-14.1%) avoided filling a prescription medication because of cost. After adjusting for demographic and health characteristics, individuals with low confidence in health insurance affordability during either the next year or retirement were significantly more likely than those with higher confidence to avoid medical care (adjusted odds ratio, 2.89; 95% CI, 1.86-4.49; P < .001) and to avoid filling a prescription medication (adjusted odds ratio, 2.87; 95% CI, 1.71-4.80; P < .001) because of cost concerns.

    Conclusions and Relevance  Many adults aged 50 to 64 years worry about their ability to afford health insurance during retirement and about potential future changes to their health insurance options associated with changes in federal policy. Policy solutions are needed to help patients better understand their coverage options and navigate health care in this critical transition period before Medicare eligibility.

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