Financial incentives can be powerful tools to influence health care behavior. The literature suggests that patients faced with high levels of cost-sharing have lower use of preventive services than patients with less cost-sharing, but there are few studies in children and only a limited number of studies in any population demonstrating that the elimination of cost-sharing increases use of prevention. This alignment of insurance benefit design with clinical goals, aka value-based insurance design (VBID), is a central feature of the recent Patient Protection and Affordable Care Act (ACA). The ACA requires that all health insurance plans eliminate cost-sharing for high value preventive services including those services recommended by the US Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) as of 2011;the ACA, however, exempts existing employer-sponsored (i.e., group) insurance plans from these policies provided that the plans do not make major changes in their benefits or prices. Thus, individuals within these """"""""grandfathered"""""""" plans continue to face the same cost-sharing for preventive care. We will exploit this natural experiment to examine how the elimination of cost-sharing for annual wellness visits and immunizations affects children and adolescents (age up to 21 years). Individuals enrolled in group health insurance plans without cost-sharing changes and tests not recommended by the USPSTF provide concurrent comparative information. Using data from the MarketScan Databases and from Kaiser Permanente, the project will examine the early clinical and economic effects of this ACA-mandated health insurance policy change on our outcomes:
Aim 1) office visit rates;
Aim 2) immunizations;
and Aim 3) total medical spending. Our data contain detailed, comprehensive information on insurance benefits, individual characteristics, immunizations, clinical events, and medical spending. The study sample includes subjects with a range of baseline cost-sharing amounts and in the timing of cost-sharing changes. Our primary analyses will focus on within-person changes (fixed effects estimation), and will adjust for a rich set of demographic, clinical, and system characteristics. With several million person-years of data, we will have adequate power to detect even small changes in our outcomes.

Public Health Relevance

This study will examine the effects of providing free wellness visits and immunizations to children and adolescents enrolled in group health insurance plans. The recent Patient Protection and Affordable Care Act requires that group insurance plans eliminate cost-sharing for these types of preventive services, but exempts many existing plans from the new rules. In other words, there are over one hundred million Americans for whom the ACA rules concerning preventive services do not apply because they are enrolled in existing group health insurance plans with grandfather status. Moreover, although providing free preventive services for children and adolescents is intuitively appealing, it is unclear whether th elimination of cost-sharing will improve access to preventive services, increase immunization rates, or affect overall medical spending. This work will inform national health policy decisions and ongoing efforts to improve the quality and efficiency of care.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Bures, Regina M
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Massachusetts General Hospital
United States
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Fung, Vicki; Peitzman, Cassandra G K; Shi, Julie et al. (2018) Adverse Selection into and within the Individual Health Insurance Market in California in 2014. Health Serv Res 53:3750-3769
Galbraith, Alison A; Fung, Vicki; Li, Lingling et al. (2018) Impact of Copayment Changes on Children's Albuterol Inhaler Use and Costs after the Clean Air Act Chlorofluorocarbon Ban. Health Serv Res 53:156-174
García-Albéniz, Xabier; Hsu, John; Hernán, Miguel A (2017) The value of explicitly emulating a target trial when using real world evidence: an application to colorectal cancer screening. Eur J Epidemiol 32:495-500
Jena, Anupam B; Huang, Jie; Fireman, Bruce et al. (2017) Screening Mammography for Free: Impact of Eliminating Cost Sharing on Cancer Screening Rates. Health Serv Res 52:191-206
Moura, Lidia Mvr; Westover, M Brandon; Kwasnik, David et al. (2017) Causal inference as an emerging statistical approach in neurology: an example for epilepsy in the elderly. Clin Epidemiol 9:9-18
Moura, Lidia Mvr; Schwamm, Eli L; Moura Junior, Valdery et al. (2016) Patient-reported financial barriers to adherence to treatment in neurology. Clinicoecon Outcomes Res 8:685-694
Moura, Lidia M V R; Carneiro, Thiago S; Cole, Andrew J et al. (2016) Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy. Patient Prefer Adherence 10:2197-2207