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Yin on Strategies to Reduce Medical Debt

Wesley Yin, associate professor of public policy and management, spoke to the podcast Tradeoffs about how Americans can reduce their medical debt. Currently, about 100 million Americans have amassed more than $140 billion in medical debt. Yin explained that simply forgiving a person’s medical bills is a short-term solution to the greater problem of accumulating medical debt. When a hospital erases debt and temporarily reduces service costs, patients became more likely to receive care; however, within six months, they are likely to go back to getting less care as their debt again piles up, a study by Yin has found. Yin and his colleagues also published a paper in JAMA showing that states with Medicaid had far less medical debt than those without it. “In the states that expanded Medicaid, the amount of debt basically was halved. And in places that didn’t, it was essentially unchanged,” he told the podcast in a segment beginning at minute 10.


 

Yin on Burden on U.S. Medical Debt

Associate Professor of Public Policy Wesley Yin’s research into the soaring cost of medical debt in the United States was featured in the UCLA Anderson Review. A study co-authored by Yin and published in the Journal of the American Medical Association found that medical bills sent to collection agencies totaled an estimated $140 billion as of June 2020. That sum, which is bigger than all other sources of debt in collection combined, was tallied even before the pandemic saddled COVID-19 sufferers with unpaid doctor and hospital bills. Medical debt is concentrated in low-income neighborhoods, in the South and in states that refused to expand Medicaid coverage under the Affordable Care Act. “Communities that had been most burdened by medical debt have become even worse off, in absolute and relative terms, due to their leaders choosing not to expand Medicaid,” Yin said. “The results are important because they indicate that these problems are within the control of public policy.”

Shah Co-Authors Report on Disproportionate COVID-19 Risk Among Latinos Local context is a key factor in the level of risk, the study of Medicaid patients in Contra Costa County finds

By Stan Paul

UCLA Luskin Professor of Public Policy Manisha Shah co-authored a study, published in the American Journal of Preventive Medicine, that showed Latinos had much higher odds of testing positive for COVID-19 than whites.

The USC-UCLA study, conducted in a Northern California regional medical center with a diverse group of adults enrolled in a county Medicaid managed care plan, also indicated a marked racial disparity in odds of hospitalization and death from COVID-19. Researchers noted that, while the coronavirus has disproportionately affected racial and ethnic minorities nationwide, in their California study, infection, hospitalization and death were higher for Latinos, but not Black patients, relative to white patients.

The researchers point out that socioeconomic differences may confound racial and ethnic differences in testing and that “the role of sociodemographic, clinical and neighborhood factors in accounting for racial/ethnic differences in COVID-19 outcomes remains unclear.”

The study included data from more than 84,000 adult Medicaid patients at Contra Costa Regional Medical Center. The researchers hypothesized that, because all of the patients had Medicaid, “racial/ethnic disparities in testing and outcomes would narrow when controlling for demographics, comorbidities and ZIP code-level characteristics.”

They also expected that these characteristics would be reduced relative to previous studies, given similar insurance coverage, household income and access to health-care providers. Among their conclusions, the researchers highlighted that racial and ethnic disparities depend on local context, citing studies from other states with differing results.

“The substantially higher risk facing Latinos should be a key consideration in California’s strategies to mitigate disease transmission and harm,” they recommend.

“We learned a lot about testing and hospitalization disparities through this study,” Shah said. “We recently implemented a randomized controlled trial with our Contra Costa County partners to better understand vaccine take-up among the vaccine hesitant.”

Shah said that the research team is testing the role of financial incentives, reducing appointment scheduling frictions, and provider messages on COVID-19 vaccine take-up in this diverse Medicaid managed care population.

“We are excited to share the results from this vaccine take-up study very soon,” Shah said.

Additional authors include Mireille Jacobson, associate professor at the USC Leonard Davis School of Gerontology and senior fellow at the USC Schaeffer School for Health Policy and Economics; Tom Chang, associate professor of finance and business economics at the USC Marshall School of Business; Samir Shah, CEO of Contra Costa Regional Medical Center; and Rajiv Pramanik at Contra Costa Regional Medical Center & Health Centers, Contra Costa Health Service.

Study Measures Americans’ Growing Medical Debt

Over the last decade, medical bills have become the largest source of debt that Americans owe collection agencies, according to new research co-authored by Associate Professor of Public Policy Wesley Yin. The $140 billion in unpaid health care bills, held by about 18% of Americans, now exceeds all other debt in collections combined, according to the paper just published in the Journal of the American Medical Association (JAMA). Only debts referred to collection agencies were measured; other unpaid bills owed to health-care providers would push the total amount of debt even higher. Yin and co-authors Raymond Kluender of Harvard Business School, Neale Mahoney of Stanford University and Francis Wong of the National Bureau of Economic Research examined records from the credit rating agency TransUnion from January 2009 to June 2020, reflecting medical care delivered prior to the COVID-19 pandemic. Their comprehensive look at the evolution of medical debt reveals that, while Americans’ household finances largely recovered after the Great Recession, medical debt continued to grow. Yin said the debt was most concentrated in low-income communities and in the South. He added that, in 12 states that chose not to expand Medicaid coverage, significant disparities grew even worse during the period studied. “Addressing the problem of medical debt in the U.S. health care system must be a high priority,” said the authors of a JAMA editorial accompanying the study. “In addition to the potential consequences for health and health care use, the economic and social ramifications of medical debt are likely equally consequential, if not more so.”


 

Now Rescinded, Trump-Era ‘Public Charge’ Policy May Still Harm Immigrants’ Health

The Trump administration’s expansion of the “public charge” rule — a move that sought to disqualify immigrants who used social programs like Medicaid from obtaining legal residency in the U.S. — led to widespread disenrollment from these programs and left scores of children in California without access to health care in the midst of the COVID-19 pandemic. What’s more, say the authors of a new report from the UCLA Latino Policy and Politics Initiative, the fear and confusion that the now-rescinded Trump-era policy sowed in the state will likely have a chilling long-term effect. The researchers’ analysis determined that the number of Latino children of immigrant parents who do not have a usual source of medical care could increase from the current level of just over 64,000 to more than 180,000 as parents avoid enrolling or disenroll their children from non-cash public assistance programs out of fear of jeopardizing their immigration status. Additionally, the researchers say, the number who have not seen a doctor within the previous 12 months could eventually jump from approximately 99,000 to almost 240,000. The public health consequences are likely to extend to U.S.-born children, who are already citizens but whose immigrant parents may fear that enrolling them in public assistance programs might limit their own path to a “green card,” or lawful permanent residency, the authors say. The report indicated that immigrant communities in Los Angeles County have been more acutely impacted by the complex and often confusing changes to immigration policies than those in any other region in the state.


 

A Spotlight on Yin’s Research on Health Insurance Literacy

The podcast Tradeoffs featured Public Policy Associate Professor Wesley Yin’s research into low enrollment rates in public health insurance plans, even when government subsidies are available. The study, which will be published in American Economics Review, noted that 60% of people who are uninsured and eligible for either Medicaid or Affordable Care Act premium tax subsidies choose to remain uninsured. In a randomized field experiment, researchers sent five types of letters to a group of uninsured, subsidy-eligible people in California. The letters contained escalating amounts of information, from merely announcing the start of open enrollment to specifying how much subsidy an individual could receive. Enrollment rates in this group increased about 16%, suggesting that this low-cost intervention increased their health insurance literacy and comfort level in navigating the system. In addition, the new enrollees were healthier, on average, than those already in the system, creating a more stable risk pool. Yin’s study is discussed in the second half of the podcast.

Aging Boom Must Be Addressed, Torres-Gil Says

Fernando Torres-Gil, director of the Center for Policy Research on Aging at UCLA Luskin, spoke to the Ventura County Star about the policy implications of the county’s aging boom. The number of Ventura County residents 60 and older — now about 196,000 — will likely exceed the number of residents younger than 18 early in 2020, local agencies reported. It also said residents age 85 and older will nearly quadruple in 40 years. Torres-Gil, professor of social welfare and public policy, said that both Democrats and Republicans have neglected restructuring Medicare, Social Security and Medi-Cal. He commended Ventura County leaders for taking the lead and creating a master plan to address the aging boom. Torres-Gil said that voters will eventually support more funding for initiatives that address the aging boom when they come to terms with their age — when they realize, ” ‘Oh [shoot], I’m old. Now what?’ ”


 

Akee on Health Care Access for Undocumented Youth

Associate Professor of Public Policy Randall Akee spoke to the Daily Bruin about Gov. Gavin Newsom’s 2019-2020 state budget and its implication for undocumented youth. Newsom’s budget would allocate $98 million to extend Medi-Cal coverage until age 26 for undocumented youth, who currently are covered until they reach the age of 19. Medi-Cal is California’s part of the federal Medicaid program, which provides free or low-cost medical services to those with limited income. Akee conducted research on the effects of losing access to Medicaid and found that emergency room visits increase when the patient does not have access to health care. Newsom’s proposal would ensure preventative care and decrease the number of costly emergency room visits, Akee argues. “They have a guaranteed source of medical coverage so they would take the preventative care that otherwise results in increased emergency room visits down the line,” he said.


 

Luskin Lecture Peers Into Future of an Aging America AARP’s Jo Ann Jenkins urges society to ‘disrupt aging’ with a fresh outlook on the nation’s increasingly older population — and how society must change as a result

By Les Dunseith

The number of Americans age 85 and older now constitutes the fastest growing segment of the U.S. population.

The second-fastest growing age group? Those age 100 and older.

The impact on society of increased longevity thanks to advances in medicine and healthier lifestyles was a centerpiece of a presentation by Jo Ann Jenkins, CEO of AARP, as part of the Meyer and Renee Luskin Lecture Series held Feb. 7, 2017.

Jenkins, whose bestselling book “Disrupt Aging” also served as the title for her lecture, talked about the necessity to rethink how we view the aging process in the years ahead.

“It’s not just about adding years to the end of life. It’s about changing the way we live throughout our lives,” Jenkins told a crowd of more than 200 people at Skirball Cultural Center. “Our ability to live longer, healthier and more productive lives is one of mankind’s greatest accomplishments. And yet we don’t see it that way. We often view it as a problem rather than an accomplishment.”

She urged the audience to think about a youngster they know today, perhaps a child or grandchild around 10 years old. Current research thinking predicts that child will have about a 50/50 chance of living to be 100.

She also noted that gerontology experts speculate that the first person who will live to be age 150 has already been born. “In this audience,” she joked, and the room erupted in laughter.

Her point, of course, is that increased longevity for a significant portion of the population not only impacts healthcare and public policy and the infrastructure of communities, but also the way people deal with the aging process and its impacts on their loved ones and themselves.

“The way people are aging is changing, but our attitudes and our stereotypes have not changed,” Jenkins said in an interview prior to the lecture. “I would like for us to be this ageless society. So that regardless of your age, you are judged on the quality of your mind and what you bring to the workplace, or what you bring into the environment. And that it’s not about being a particular age.”

Coping with the societal impact of the demographic reality is a challenge that “we find ourselves woefully unprepared” to deal with, said UCLA Luskin urban planning professor Anastasia Loukaitou-Sideris, who is also UCLA’s associate provost for academic planning. “Most seniors live in cities, but the cities are not really designed, planned or developed for them.”

New policies and approaches are needed to successfully adjust to an aging population. “Older adults are equal citizens who have a right to expect the same rights and benefits and amenities from cities as other groups,” Loukaitou-Sideris said. “This is not yet happening. The onus is on the people who are the city builders, the policymakers, the planners, the politicians.”

Because those are the types of people who work and study at the UCLA Luskin School of Public Affairs, hosting a visit by Jenkins was a natural fit. She is the CEO of an influential national organization that has about 38 million members over age 50.

The Luskin Lecture by Jenkins was also an example of a growing relationship between the university and AARP that was fostered by Fernando Torres-Gil, professor of social welfare and public policy, over the past few years while he served on the organization’s board of directors.

“UCLA is the premier university when it comes to geriatrics and the biomedical side of gerontology,” Torres-Gil said in advance of the lecture. “UCLA, as a university, has tremendous research strength in issues of aging.”

AARP is “beginning to understand what we can do for them,” he said about UCLA and its research, educational and planning capabilities. “In a nation becoming old and moving to majority-minority status, AARP needs to take a leadership role in responding to multicultural populations and the nexus with aging.”

People at UCLA in fields of study such as medicine, gerontology, public policy and urban planning “have an enormous opportunity to rethink the course of life,” Jenkins said. “If we are going to live to be 100, how might that change the way we educate — not only the youth, but all of us — throughout the lifespan?”

California and Los Angeles, in particular, present a perfect opportunity for organizations such as AARP to achieve a better understanding of the needs of older Americans from diverse ethnic and cultural backgrounds. One aspect of that effort is a $300,000 grant from AARP to help fund the research of faculty members such as Loukaitou-Sideris, whose studies of the public environment in and around cities have previously noted shortcomings related to the needs of older residents, particularly those in minority populations.

In a question and answer session that followed the lecture and was moderated by Torres-Gil, he asked for Jenkins’ perspective on diversity given the fact that so many of those entering old age are from ethnic minority populations.

“We at AARP have a huge role to play in showing how nonprofit organizations ought to be community partners at the local level,” Jenkins responded. “Our goal at AARP is to be in your life every day, concerned about the issues that are important to you, not just necessarily about what’s important to AARP. And that absolutely includes diverse communities all across this country.”

Not only are people living longer, but their expectations for quality of life are changing as well. This notion of rethinking what it means to grow old is one that Jenkins has championed since she became the leader of AARP in 2014, and it is the core message of “Disrupt Aging.”

“We ought to accept our age and feel good about where we are in life,” Jenkins said. “Among our members, many of them are not retiring. They might be leaving a particular job, but it’s to do something different.”

Still, she noted, American society is obsessed with age. When people are asked what they are most likely to lie about, age is the top answer. “But what if we could eliminate our preoccupation with a number? For example, what if we decided that middle age started at 65? What would that do to your own preconceptions?” Jenkins asked.

“It’s not our own aging that we need to fight against,” Jenkins said during the lecture. “It’s the ageist attitudes and perceptions that permeate society and play such a huge role in our culture.”

She acknowledged that aging does create challenges that older Americans wrestle with every day. “As we get older, many of us find things that we have always taken for granted more difficult to achieve,” she said. “Our wants and our needs change, but our environment does not always adapt to address those changes.”

In her view, the capacity to deal successfully with that reality is an issue that impacts individuals, governments and businesses in equal measure. “We blame ourselves. Instead of changing our environment to fit our needs, we bemoan getting older,” she said.

Efforts by AARP and by researchers such as Loukaitou-Sideris seek ways to make communities more livable for an aging population. Jenkins cited a research example that focuses on the fact that many older people have trouble getting in and out of a car.

“We attribute it to the weakening of the leg muscles and the loss of sense of balance rather than considering the inadequacies of a car seat that does not swivel and allow us to emerge straight forward rather than trying to slide out of the car sideways,” Jenkins said. “Car seats were not made with a 75-year-old in mind.”

The idea of refocusing our thinking to better accommodate an aging population also applies to communities and housing. Today, more people are living into their 80s and 90s and want to stay in their homes as long as possible.

“Basic access should be built into the homes, just like wiring and plumbing,” Jenkins said. “Living in a community with services nearby and having a home that accommodates our needs are tremendous assets for those of us who want to age in place.”