Alcohol regulations work better than expected. Affordable Care Act Exchanges might not. This is Healthcare Triage News...

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From the BMJ Journal of Epidemiology and Community Health, "Measurable Effects of Local Alcohol Licensing Policies on Population Health in England." Often, when we talk about many public health related issues, people will say there's nothing we can do. That's not always the case. We know of the dangers of alcohol. In the United Kingdom, about a third of women and more men drink more than is considered okay. Some laws in the UK allow for the limiting of the number of new alcohol outlets in areas where they might cause problems (affecting crime or public safety, cause problems or impacting children). Researchers developed a measure of how much these zones and regulations were used. Then they looked at whether regulation was related to changes in alcohol related hospital admissions and crime rates. They found that in areas with more intense alcohol licensing policies there were bigger reductions in alcohol-related admission rates. They also found a "dose response". Specific areas with the most intensive licensing policies had 5% greater reduction (p=0.006) in 2015 compared to those with no policies. 

There are limitations of course. It's possible that changes in admissions are caused by changes in disease and not in incidence. It's possible that visits went from inpatient to outpatient. It's possible something unmeasured is at play. But this is still interesting, or at lease worth looking into further.

Our second story is an Affordable Care Act Update. The Obama Administration recently made news by announcing that the number of people expected to obtain insurance under the Exchanges will fall far short of previous projections. Specifically, they're now expecting that about 10 million people to enroll in private exchange plans in 2016, compared to the 13 million that were previously thought might enroll not long ago. Why so many fewer? The Commonwealth Fund asked about that in their most recent Affordable Care Act tracking survey. They analyzed responses from people who visited the exchanges but did not decide to enroll in any insurance plans. About 25& of working-age adults had visited the marketplaces to shop for health insurance by Spring of 2015. About half of them eventually purchased health insurance, enrolling in a private plan about twice as often as Medicaid. When considering those who did not choose to enroll, more than half (57%) reported that they could not find a plan that they could afford. More than a third (38%) reported that they found the process difficult or confusing. And 43% found that they were not eligible to enroll in Medicaid or get financial assistance. 

The cost of insurance is still the major driver of uninsurance. This could be fixed with more generous subsidies but such a change is unlikely to occur any time soon. Increasing uptake of the Medicaid expansion would also make a difference, but that too is politically fraught, especially in an election year. There are other options, however. People who received personal assistance in shopping for plans were much more likely to obtain them. Almost 80% of those who had help eventually signed up for coverage, versus 56% of those who didn't. This may be because without help, it's very hard to make decisions about health insurance. About half of people who didn't obtain coverage reported that it was difficult to compare premium costs. More than that had difficulty understanding differences in benefits covered, potential out of pocket costs, and who might be in and out of networks. This could also be a problem with information dissemination. More than half of the people who didn't enroll because of the cost of insurance, were ELIGIBLE FOR SUBSIDIES. It's not clear whether the subsidies were inadequate, or whether they understood they were eligible at all. That's the crucial thing to consider here. It is becoming abundantly clear that the Affordable Care Act has significantly reduced the numbers of the uninsured in the United States. it's also becoming clear that there is still much work to be done to reduce those numbers further. People need help to sign up for insurance. Whether we choose to give it to them is up to those implementing the policy. 



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