Showing papers by "Urban Institute published in 2016"

A National Profile of Family and Unpaid Caregivers Who Assist Older Adults With Health Care Activities

Abstract: Importance Family and unpaid caregivers commonly help older adults who are at high risk for poorly coordinated care. Objective To examine how caregivers’ involvement in older adults’ health care activities relates to caregiving responsibilities, supportive services use, and caregiving-related effects. Design, Setting, and Participants A total of 1739 family and unpaid caregivers of 1171 community-dwelling older adults with disabilities who participated in the 2011 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC). Main Outcomes and Measures Caregiving-related effects, including emotional, physical, and financial difficulty; participation restrictions in valued activities; and work productivity loss. Exposures Caregivers assisting older adults who provide substantial, some, or no help with health care, defined by coordinating care and managing medications (help with both, either, or neither activity, respectively). Results Based on NHATS and NSOC responses from 1739 family and unpaid caregivers of 1171 older adults with disabilities, weighted estimates were produced that accounted for the sampling designs of each survey. From these weighted estimates, 14.7 million caregivers assisting 7.7 million older adults, 6.5 million (44.1%) provided substantial help, 4.4 million (29.8%) provided some help, and 3.8 million (26.1%) provided no help with health care. Almost half (45.5%) of the caregivers providing substantial help with health care assisted an older adult with dementia. Caregivers providing substantial help with health care provided more hours of assistance per week than caregivers providing some or no help (28.1 vs 15.1 and 8.3 hours, P P Conclusions and Relevance Family caregivers providing substantial assistance with health care experience significant emotional difficulty and role-related effects, yet only one-quarter use supportive services.

Challenges, solutions and future directions in the evaluation of service innovations in health care and public health

Abstract: Policies and interventions in the health-care system may have a wide range of effects on multiple patient outcomes and operate through many clinical processes. This presents a challenge for their evaluation, especially when the effect on any one patient is small. In this essay, we explore the nature of the health-care system and discuss how the empirical evidence produced within it relates to the underlying processes governing patient outcomes. We argue for an evidence synthesis framework that first models the underlying phenomena common across different health-care settings and then makes inferences regarding these phenomena from data. Bayesian methods are recommended. We provide the examples of electronic prescribing and increased consultant provision at the weekend.

Within- and between-sector quality differences in early childhood education and care.

Abstract: This study leverages nationally representative data (N ≈ 6,000) to examine the magnitude of quality differences between (a) formal and informal early childhood education and care providers; (b) Head Start, prekindergarten, and other center-based care; and (c) programs serving toddlers and those serving preschoolers. It then documents differences in children's reading and math skills at age 5 between those who had enrolled in formal and informal settings. Cross-sector differences are substantially reduced when accounting for a set of quality measures, though these measures do less to explain more modest differences in outcomes within the formal sector. Results inform current efforts aimed at improving the quality of early childhood settings by highlighting the large quality differences across sectors and their relationship with child development.

Access To Care And Affordability Have Improved Following Affordable Care Act Implementation; Problems Remain

Abstract: There is growing evidence that millions of adults have gained insurance coverage under the Affordable Care Act, but less is known about how access to and affordability of care may be changing. This study used data from the Health Reform Monitoring Survey to describe changes in access and affordability for nonelderly adults from September 2013, just prior to the first open enrollment period in the Marketplace, to March 2015, after the end of the second open enrollment period. Overall, we found strong improvements in access to care for all nonelderly adults and across income and state Medicaid expansion groups. We also found improvements in the affordability of care for all adults and for low- and moderate-income adults. Despite this progress, there were still large gaps in access and affordability in March 2015, particularly for low-income adults.

Association Between the 2014 Medicaid Expansion and US Hospital Finances.

Abstract: Importance The Affordable Care Act expanded Medicaid eligibility for millions of low-income adults. The choice for states to expand Medicaid could affect the financial health of hospitals by decreasing the proportion of patient volume and unreimbursed expenses attributable to uninsured patients while increasing revenue from newly covered patients. Objective To estimate the association between the Medicaid expansion in 2014 and hospital finances by assessing differences between hospitals in states that expanded Medicaid and in those states that did not expand Medicaid. Design and Setting Observational study with analysis of data for nonfederal general medical or surgical hospitals in fiscal years 2011 through 2014, using data from the American Hospital Association Annual Survey and the Health Care Cost Report Information System from the US Centers for Medicare & Medicaid Services. Multivariable difference-in-difference regression analyses were used to compare states with Medicaid expansion with states without Medicaid expansion. Hospitals in states that expanded Medicaid eligibility before January 2014 were excluded. Exposures Medicaid expansion in 2014, accounting for variation in fiscal year start dates. Main Outcomes and Measures Hospital-reported information on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins. Results The sample included between 1200 and 1400 hospitals per fiscal year in 19 states with Medicaid expansion and between 2200 and 2400 hospitals per fiscal year in 25 states without Medicaid expansion (with sample size varying depending on the outcome measured). Expansion of Medicaid was associated with a decline of $2.8 million (95% CI, −$4.1 to −$1.6 million; P P = .008) in mean annual Medicaid revenue per hospital, relative to hospitals in states without Medicaid expansion. Medicaid expansion was also significantly associated with improved excess margins (1.1 percentage points [95% CI, 0.1 to 2.0 percentage points]; P = .04), but not improved operating margins (1.1 percentage points [95% CI, −0.1 to 2.3 percentage points]; P = .06). Conclusions and Relevance The hospitals located in the 19 states that implemented the Medicaid expansion had significantly increased Medicaid revenue, decreased uncompensated care costs, and improvements in profit margins compared with hospitals located in the 25 states that did not expand Medicaid. Further study is needed to assess longer-term implications of this policy change on hospitals’ overall finances.

California's Early Coverage Expansion under the Affordable Care Act: A County-Level Analysis

Abstract: Objective To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an “early expansion” under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes. Data Sources/Study Setting 2008–2012 American Community Survey (ACS). The sample contained California adults ages 19–64 years (n = 237,876) and children 0–18 years (n = 113,159) with incomes below 200 percent of the federal poverty level. Study Design Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children. Principal Findings Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment. Conclusions California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA.

Understanding Medicare Hospital Readmission Rates And Differing Penalties Between Safety-Net And Other Hospitals

Abstract: Since the implementation of Medicare’s Hospital Readmissions Reduction Program in 2012, concerns have been raised about the effect its payment penalties for excess readmissions may have on safety-net hospitals. A number of policy solutions have been proposed to ensure that the program does not unfairly penalize safety-net institutions, which treat a disproportionate number of patients with low socioeconomic status. We examined the extent to which the program’s current risk-adjustment factors, measures of patient socioeconomic status, and hospital-level factors explain the observed differences in readmission rates between safety-net and other hospitals. Our analyses suggest that patient socioeconomic status can explain some of the difference in readmission rates but that unmeasured factors such as hospitals’ performance may also play a role. We also found that safety-net hospitals have experienced only slightly higher readmission penalties under the program than other hospitals have. Together, these findin...

Active Life Expectancy In The Older US Population, 1982–2011: Differences Between Blacks And Whites Persisted

Abstract: Understanding long-range trends in longevity and disability is useful for projecting the likely impact of the baby-boom generation on long-term care utilization and spending. We examine changes in active life expectancy in the United States from 1982 to 2011 for white and black adults ages sixty-five and older. For whites, longevity increased, disability was postponed to older ages, the locus of care shifted from nursing facilities to community settings, and the proportion of life at older ages spent without disability increased. In contrast, for blacks, longevity increases were accompanied by smaller postponements in disability, and the percentage of remaining life spent active remained stable and well below that of whites. Older black women were especially disadvantaged in 2011 in terms of the proportion of years expected to be lived without disability. Public health measures directed at older black adults—particularly women—are needed to offset impending pressures on the long-term care delivery system ...

Who Gained Health Insurance Coverage under the ACA, and Where Do They Live?

Abstract: The Affordable Care Act (ACA) is credited with reducing the number of uninsured by 20 million and bringing the uninsurance rate to a historic low. In this brief, we take a detailed look at changes in health insurance coverage among the nonelderly population from 2010 to 2015. We use data from the American Community Survey to compute uninsured rates for the nation, individual states, and demographic groups. We find that gains in coverage were large and broad-based for all Americans under 65, for both men and women, and across subgroups based on race/ethnicity, levels of educational attainment, and states. Congress is now considering options to repeal the ACA; removal of key provisions without new policies capable of maintaining these coverage gains would result in millions of Americans, of all ages and backgrounds and in all states, losing health insurance.

Financial Transaction Taxes in Theory and Practice

Abstract: We explore issues related to a financial transaction tax (FTT) in the United States. We trace the history and current practice of the tax in the United States and other countries, review evidence of its impact on financial markets, and explore the key design issues any such tax must address. We present new revenue and distributional effects of a hypothetical relatively broad-based FTT in the United States, finding that, at a base rate of 0.34 percent, it could raise a maximum of about 0.4 percent of GDP ($75 billion in 2017) in a highly progressive manner.

Medicaid Expansions from 1997 to 2009 Increased Coverage and Improved Access and Mental Health Outcomes for Low‐Income Parents

Abstract: Objective To assess the effects of past Medicaid eligibility expansions to parents on coverage, access to care, out-of-pocket (OOP) spending, and mental health outcomes, and consider implications for the Affordable Care Act (ACA) Medicaid expansion. Data Sources Person-level data from the National Health Interview Survey (1998–2010) is used to measure insurance coverage and related outcomes for low-income parents. Using state identifiers available at the National Center for Health Statistics Research Data Center, we attach state Medicaid eligibility thresholds for parents collected from a variety of sources to NHIS observations. Study Design We use changes in the Medicaid eligibility threshold for parents within states over time to identify the effects of changes in eligibility on low-income parents. Principal Findings We find that expanding Medicaid eligibility increases insurance coverage, reduces unmet needs due to cost and OOP spending, and improves mental health status among low-income parents. Moreover, our findings suggest that uninsured populations in states not currently participating in the ACA Medicaid expansion would experience even larger improvements in coverage and related outcomes than those in participating states if they chose to expand eligibility. Conclusions The ACA Medicaid expansion has the potential to improve a wide variety of coverage, access, financial, and health outcomes for uninsured parents in states that choose to expand coverage.

Financial transaction taxes in theory and practice

Abstract: We explore issues related to a financial transaction tax (FTT) in the United States. We trace the history and current practice of the tax in the United States and other countries, review evidence o...

How to Use Carbon Tax Revenues

Abstract: How should governments use the considerable revenue carbon taxes can raise? There are many options for cutting other taxes, increasing spending, or reducing borrowing. We organize the options into four goals: offset the new burdens that a carbon tax places on consumers, producers, communities, and the broader economy; support further efforts to reduce greenhouse gas emissions; ameliorate the harms of climate disruption; and fund unrelated public priorities. We identify important tradeoffs across the goals and make several recommendations for policy design. Revenue neutrality, for example, can assuage public concerns about expanding government, but spending may be better than tax reductions for achieving some goals. We recommend that governments use some revenue to reduce other taxes and to soften the blow to lower-income households, coal workers, and their communities, that they be cautious about using revenues to pursue emissions reductions the tax itself encourages, and that they avoid tight earmarks. Governments should also pay special attention to using revenue in ways that attract and sustain stakeholder and public support for a carbon tax.

A Passage to America: University Funding and International Students

Abstract: The pool of students in the global economy prepared for higher education and able to pay tuition at U.S. colleges and universities has expanded markedly in the last two decades, with a particularly notable increase among potential undergraduate students from China. Given the concentration of high quality colleges and universities in the U.S., there has been a substantial increase in the demand for enrollment among students from abroad. At the same time, substantial declines in state support, driven by contractions in state budgets, have occurred at public sector universities. For such universities, declines in state appropriations force a choice between increasing tuition levels, cutting expenditures, or enrolling a greater proportion of students paying full out-of-state tuition. In this paper we present evidence showing that a significant set of public universities were able to take advantage of the expanding pool of potential students from abroad to provide a stream of tuition revenue that partially offsets declining state appropriations. Our analysis focuses on the interaction between the type of university experience demanded by students from abroad and the supply-side of the U.S. market. For the period between 1996 and 2012, we estimate that a 10% reduction in state appropriations is associated with an increase in foreign enrollment of 12% at public research universities and about 17% at the most resource-intensive public universities. Our results tell a compelling story about the link between changes in state funding and foreign enrollment in recent years. In the absence of the pool of foreign students, many universities would have faced larger cuts to expenditures and potentially greater increases in in-state tuition charges.

Finding Value in Unexpected Places — Fixing the Medicare Physician Fee Schedule

Abstract: A substantially improved, carefully managed Medicare Physician Fee Schedule could pave the way to more fundamental value-based payment reform and improve performance among physicians, who are likely to be paid according to fee schedules for the foreseeable future.

Immigration Status and the Healthcare Access and Health of Children of Immigrants

Abstract: Objective In this article, I examine how children's and parents’ immigration status (U.S. born, legal immigrant, or undocumented) is associated with children's access to insurance and healthcare and with children's physical health. Methods I use the first wave of the Los Angeles Family and Neighborhood Survey, which is representative of Los Angeles County in 2000–2001, to analyze data on parents' and children's immigration status, children's health insurance coverage, children's healthcare utilization, and children's health, using logistic and ordered logistic regression models. Results I find that undocumented immigrant children face severely constrained access to health insurance and a usual source of healthcare, while children with foreign-born parents have lower global health status than children with U.S.-born parents. Children with undocumented parents may have less access to a doctor diagnosis for common childhood ailments. Conclusion These results show that without being eligible for public insurance, many undocumented children lack health insurance and a usual healthcare provider, even in a part of the country with substantial experience serving immigrant families.

Drivers of Racial and Ethnic Disparities in Cardiac Rehabilitation Use: Patient and Provider Perspectives.

Abstract: Cardiac rehabilitation (CR) use is lower for racial and ethnic minorities than White patients. The purpose of this study was to identify factors that drive this disparity at the system, provider, and patient levels. A mixed methods study combined descriptive analysis of 2007 Medicare claims data and thematic analysis of 19 clinician interviews, 8 minority patient focus groups and 8 one-on-one interviews with minority heart patients across three communities. The disparity between White and non-White CR use ranged from 7 to 11 percentage points among study sites (p < .05). Key themes suggest disparities are driven by (a) flawed financing and reimbursement that creates disincentives to invest in CR programs, (b) a health care system whose priorities are misaligned with the needs of patients, and (c) subjective decision-making around referral processes. These findings suggest that the health care system needs to address multiple levels of problems to mitigate disparities in CR use.

Relationship Status and Long-Term Care Facility Use in Later Life

Abstract: Objectives Most older adults prefer to "age in place" and avoid formal long-term care. Yet demographic shifts, including population aging and an increasing prevalence of remarried and unmarried older adults, could undermine these goals, making it important to consider carefully how and why relationship status relates to long-term care risk. Method We fit hazard models to a sample of adults aged 65 and older from eight waves (1998-2012) of the Health and Retirement Study (N = 21,564). We consider risk of any long-term care facility admission, as well as risk of long-duration stays. Results Widowed, divorced, and never married adults have the highest risks of long-term care admission. Remarried and partnered adults have similar risks of long-term care admission as continuously married adults. Relationship status is more important for men than for women, especially when considering long-duration stays. Relationship status is also more significant for non-Hispanic White and Hispanic adults compared with non-Hispanic Black adults. Economic resources and, to some extent, social ties partially explain the association between relationship status and long-term care use. Discussion By addressing the prohibitive costs of long-term care services which enable aging in place (e.g., home health care), relationship status disparities in long-term care may be reduced. Future studies should consider the link between long-term care facility use and relationship status in future cohorts as well as examine how relationship status structures access to a range of long-term care options.

Social Bonds, Juvenile Delinquency, and Korean Adolescents: Intra- and Inter-Individual Implications of Hirschi’s Social Bonds Theory Using Panel Data

Abstract: Social bonds theory is one of the most influential and tested perspectives for explaining juvenile delinquency, yet tests have often been methodologically limited. Prior research has failed to examine how intra- and interindividual variation in social bonding influences delinquency. In addition, there are few applications of this theory to non-Western contexts. Thus, the current study attempts to test the cross-cultural generalizability of social bonds theory and overcome weaknesses of prior research. We use longitudinal panel analyses and five waves of data from the Korean Youth Panel Survey to examine the influence of nine measures of social bonding on delinquent behavior. By estimating different panel models, we find some support for social bonds as indicators of within- and between-individual variation in delinquency. Specifically, the emphasis on education in Korea and the role of parents in supervising their children play an integral role in reducing the delinquency of Korean youth.

The Impact of United States v. Booker and Gall/Kimbrough v. United States on Sentence Severity Assessing Social Context and Judicial Discretion

Abstract: In the wake of United States v Booker and Gall/Kimbrough v United States, sentencing researchers and legal scholars conducted research designed to identify their impact on the federal sentencing process, with a focus on determining whether the decisions increased unwarranted disparity In this article, we extend this body of research Using 10 years of data from the US Sentencing Commission and data from other sources, we assess whether and how these decisions influence sentence severity Results indicate that sentence severity declined following Booker and, especially, Gall/Kimbrough, but that the decisions’ effects on sentence severity varied significantly across US District Courts Most importantly, the impact of Gall/Kimbrough sentence severity was conditioned by districts’ percent Black population, level of socioeconomic disadvantage, and degree of political conservatism; each of these factors moderated the decisions’ effects on the harshness of the sentences imposed by the districts’ judges

Successful Aging Through Successful Accommodation With Assistive Devices

Abstract: Objectives To provide a profile of older adults who successfully accommodate declines in capacity by using assistive devices. Method Using the National Health and Aging Trends Study, we provide national estimates of prevalent, incident, and persistent successful accommodation of mobility and self-care activity limitations. For incident and persistent accommodation groups, we describe their subjective wellbeing and participation restrictions, health and functioning, demographic and socioeconomic characteristics, and acquisition of assistive devices and environmental features. We estimate regression models predicting incident and persistent successful accommodation and the extent of wellbeing and participation restrictions for incident and persistent groups (vs. those who are fully able). Results Nearly one-quarter of older adults have put in place accommodations that allow them to carry out daily activities with no assistance or difficulty. In adjusted models, incident and persistent successful accommodation is more common for those ages 80-89, those with more children, and those living in homes with environmental features already installed; wellbeing levels for these groups are similar and participation restrictions only slightly below those who are fully able. Discussion A focus on facilitating successful accommodation among those who experience declines in capacity may be an effective means of promoting participation and wellbeing in later life.

Family Planning and Preconception Health Among Men in Their Mid-30s: Developing Indicators and Describing Need.

Abstract: The Centers for Disease Control and Prevention and Healthy People 2020 call for improvements in meeting men’s reproductive health needs but little is known about the proportion of men in need. This...

Why High-Poverty Neighborhoods Persist The Role of Precarious Housing

Abstract: Why do we see persistence, recurrence, and new emergence of concentrated poverty in U.S. cities? In this article, we explore an understudied connection: whether an important part of the built environment—a series of attributes that constitute precarious housing—constitutes a durable substrate on which concentrated poverty predictably emerges and recurs and if so, how this might vary across the United States. Poverty grew fastest between 2000 and 2005–2009 in tracts that began the decade with high levels of rented one- to four-family housing, multifamily housing, housing between 20 and 25 years old, and households paying over 30% of their income for housing costs. In addition, poverty grew fastest in tracts with high percentages of black or Hispanic households in 2000.

Skill Development in Middle Level Occupations: The Role of Apprenticeship Training

Abstract: Concerns about the polarization of the labor market are widespread. However, countries vary widely in strategies for strengthening jobs at intermediate levels of skill. This paper examines the diversity of approaches to apprenticeship and related training for middle-level occupations. We begin by defining and describing middle-skills occupations, largely in terms of education and experience. The next step is to describe skill requirements and alternative approaches to preparing and upgrading the skills of individuals for these occupations. Programs of academic education and apprenticeship programs emphasizing work-based learning have often competed for the same space but the full picture reveals significant numbers of complementarities. Third, we consider the evidence on the costs and effectiveness of apprenticeship training in several countries. The final section highlights empirical and policy research results concerning the advantages of apprenticeship training for intermediate level skills, jobs, and careers.

The Dwindling Taxable Share of U.S. Corporate Stock

Abstract: The share of U.S. stocks held in taxable accounts has declined sharply over the last 50 years, which has important implications for how best to tax corporate earnings (which, purportedly, are double-taxed).

Marketplaces Helped Drive Coverage Gains In 2015; Affordability Problems Remained.

Abstract: Health insurance coverage through the Marketplaces increased in 2015, with more nonelderly adult enrollees insured all year and fewer reporting health care affordability problems than in 2014. In 2015 more Marketplace enrollees in Medicaid nonexpansion states reported trouble paying family medical bills, compared to those in expansion states (23 percent versus 15 percent).

Closing the Racial Wealth Gap: Establishing and Sustaining an Initiative

Abstract: By 2003, the savings and asset building field had achieved critical research and policy successes. However, some challenges it faced were the lack of a substantial presence of organizations of color in the field and the absence of experts of color at decision-making tables. Over the course of 11 years, a strategy was developed within the Ford Foundation to gain an understanding of the knowledge and perspective of communities of color about saving and wealth building and to then include this perspective within the asset building field. This article provides a social history of the work undertaken to create and sustain this initiative.

A Renter or Homeowner Nation

Abstract: This article performs an exercise in which we identify the potential impact of key drivers of home ownership rates on home ownership outcomes by 2050. We take no position on whether these key determinants in fact will come about. Rather we perform an exercise in which we test for their impact. We demonstrate the result of shifts in three key drivers for home ownership forecasts: demographics (projected from the census), credit conditions (reflected in the fast and slow scenarios), and rents and housing cost increases (based on California). Our base case average scenario forecasts a decrease in home ownership to 57.9 percent by 2050, but alternate simulations show that it is possible for the home ownership rate to decline from current levels of around 64 percent to around 50 percent by 2050, 20 percentage points less than at its peak in 2004. Projected declines in home ownership are about equally due to demographic shifts, continuation of recent credit conditions, and potential rent and house price increases over the long term. The current and post WW II normal of two out of three households owning may also be in our future: if credit conditions improve, if (as we move to a majority-minority nation) minorities' economic endowments move toward replicating those of majority households, and if recent rent growth relative to income stabilizes.

Instructional Quality and Student Learning in Higher Education: Evidence from Developmental Algebra Courses

Abstract: Little is known about the importance of instructional quality in American higher education because few recent studies have had access to direct measures of student learning that are comparable across sections of the same course. Using data from two developmental algebra courses at a large community college, I found that student learning varies systematically across instructors and was correlated with observed instructor characteristics including education, full-time status, and experience. Instructors appeared to have effects on student learning beyond their impact on course completion rates. A variety of robustness checks suggested that these results do not appear to be driven by nonrandom matching of students and instructors based on unobserved characteristics or censoring of the dependent variable due to students who dropped the course before the final exam.