Beginning in 2014, individuals and small businesses are able to purchase private health insurance through competitive Marketplaces. The Affordable Care Act (ACA) provides for a program of risk adjustment in the individual and small group markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge. The risk adjustment methodology includes the risk adjustment model and the risk transfer formula.This article is the second of three in this issue of the Review that describe the Department of Health and Human Services (HHS) risk adjustment methodology and focuses on the risk adjustment model. In our first companion article, we discuss the key issues and choices in developing the methodology. In this article, we present the risk adjustment model, which is named the HHSHierarchical Condition Categories (HHS-HCC) risk adjustment model. We first summarize the HHS-HCC diagnostic classification, which is the key element of the risk adjustment model. Then the data and methods, results, and evaluation of the risk adjustment model are presented. Fifteen separate models are developed. For each age group (adult, child, and infant), a model is developed for each cost sharing level (platinum, gold, silver, and bronze metal levels, as well as catastrophic plans). Evaluation of the risk adjustment models shows good predictive accuracy, both for individuals and for groups. Lastly, this article provides examples of how the model output is used to calculate risk scores, which are an input into the risk transfer formula. Our third companion paper describes the risk transfer formula.

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Key Points Question How did hospitalizations and racial and ethnic disparities in hospitalization outcomes change during the COVID-19 pandemic among patients with traditional Medicare? Findings In this cohort study using 100% traditional Medicare inpatient data, comprising 31 771 054 beneficiaries and 14 021 285 hospitalizations from January 2019 through February 2021, the decline in non–COVID-19 and emergence of COVID-19 hospitalizations during the pandemic was qualitatively similar among beneficiaries of different racial and ethnic minority groups. In-hospital mortality for patients with COVID-19 was higher in racial and ethnic minority groups than in White patients, driven by a Hispanic-White gap; mortality among non–COVID-19 hospitalizations also differentially increased among patients in racial and ethnic minority groups relative to White patients, driven by an increased Black-White gap. Meaning Racial and ethnic disparities in mortality were evident among COVID-19 hospitalizations and widened among non–COVID-19 hospitalizations among Medicare beneficiaries, motivating greater attention to health equity.

Worker Protection Standard (WPS) training is one of the U.S. Environmental Protection Agency's (EPA) primary methods for preventing pesticide exposure in agricultural workers. Retention of the knowledge from the training may occasionally be tested by state Occupational Safety and Health Administrations (state OSHAs) during a site visit, but anecdotal evidence suggests that there is no consistent testing of knowledge after WPS training. EPA's retraining requirements are at 5-year intervals, meaning the knowledge must be retained for that long. Vineyard workers completed a test of their baseline WPS knowledge, computer-based training on WPS, a post-test immediately after training and a re-test 5 months later. Pre-test performance suggested that there was a relatively high level of baseline knowledge of WPS information on two-answer multiple choice tests (74% to 75%) prior to training. Training increased the knowledge to 85% on the post-test with the same questions, a significant increase (p < .001, 1-tailed) and a large effect size (d) of .90. Re-test performance (78%) at 5 months revealed a return towards but not back to the pre-test levels. Better test performance was significantly correlated with higher education and to a lesser extent with younger ages. Whether this level of knowledge is sufficient to protect agricultural workers remains an open question, although an increase in the proportion of people in a work group who know the critical WPS information may be the most important impact of training.

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