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Termination from Medicaid: how does it affect access, continuity of care, and willingness to purchase insurance?

Welfare reform has raised fears that Medicaid recipients will lose coverage, yet efforts to insure the poor via waiver programs may fall short. A telephone sample of 351 enrolled and terminated members of a Medicaid managed care plan based in community health centers were asked about insurance status, source of care, willingness to purchase new insurance, and access. Of terminated families, 78 percent had one member without insurance, 93 percent retained a regular source of care (vs. 96 percent enrolled), and 86 percent retained the same source as before losing coverage. Only 11 percent of uninsured respondents were willing to pay $200 per month and 57 percent to pay $50 per month for replacement coverage, and they were more likely to report problems getting prescription medications and obtaining treatment for serious symptoms and to go without care because of the expense. Access to care is diminished for those who lose Medicaid coverage, even for persons attending community health centers.

Adult↗

Economic costs of alcohol abuse and alcoholism.

The economic cost to society from alcohol abuse and alcoholism in the United States was an estimated $148 billion in 1992. When adjusted for inflation and population, the estimates are generally comparable with cost estimates produced over the past 20 years. The current estimates are significantly greater than the most recent detailed estimates developed for 1985--about 42% above increases due to population growth and inflation. Between 1985 and 1992, inflation accounted for about 37.5% and population growth for 7.1% increases. Changes in prevalence have been associated with a modest reduction in alcohol costs. Though crime rates did not materially change over this period, criminal justice expenditures more than doubled overall, even after adjustment for price increases. The balance of changes are due to new findings and/or methodology indicating larger impacts than previously estimated. It is estimated that 45.1% of costs are borne by alcohol abusers and/or members of their households, 38.6% are borne by government, 10.2% by private insurance, and 6.0% by victims of alcohol-related trauma (motor vehicle crashes plus crime). The costs staying in the household of the abusers may be materially incident on persons other than the abuser, e.g., spouses, children.

Adult↗

Considerations in asset allocation: investing wisely.

BACKGROUND: In this article, the author reviews the steps an investor should take to make sound asset allocation decisions and offers guidelines on assembling a portfolio that helps meet the investor's needs. CONCLUSIONS: The most important decision in structuring a broadly diversified investment portfolio is the allocation among and within the three major asset classes: stocks, bonds and short-term reserves. In selecting the appropriate mix, the investor should weigh four interrelated factors-investment objective, time horizon, risk tolerance and personal financial situation. PRACTICE IMPLICATIONS: A well-diversified investment portfolio and a disciplined savings program are important factors in reaching financial goals.

Dentists↗

Economic role of solidarity and social capital in accessing modern health care services in the Ivory Coast.

At the beginning of the 1990s, health service reforms were implemented in public health institutions in most African countries South of the Sahara. In the Ivory Coast, the imposition of user fees for public services was adopted in 1994. Such fees require each person to have adequate financial resources in order to access modern health care services. Many poor people--despite their poverty--are able to access modern health care services that have become quite expensive. The factor that allows this access lies within the solidarity of parents, friends or members of a social network. In Africa, illness is a social phenomenon and a state of illness is negative. The sick human being is one who cannot fully participate in community life. The treatment of a sick person is, then, an act, which is tied to the systems of life, which are produced and maintained collectively. Once the causes of illness are identified and consequences evaluated, it is the entire family or group that participates in the finances which bring about treatment. In this study, we show the role of social capital in the processes of financial solidarity for access to modern health care services that now require payment. Our investigation provides valuable insights on the role of social capital with respect to social strategies and community financing mechanisms for the acquisition of modern health care in Africa.

Attitude to Health↗

Out-of-pocket health expenditure differentials between elderly and non-elderly households.

Regression analysis was used to compare out-of-pocket health expenditures between lower and higher income elderly and non-elderly households. Race and housing tenure were significant determinants for both age groups, but assets, education, and family size were significant only for the non-elderly. Analysis of out-of-pocket health costs indicated greater equity among elderly persons, probably due to Medicare, but income elasticities revealed that health spending is a luxury for lower income elderly households.

Adult↗

The organization and financing of health services for persons with disabilities.

Americans with disabilities are rarely considered a distinct group of health care users in the same way as are older Americans, children, racial and ethnic minorities, and others who are perceived to have different needs and access issues. Indeed, to some extent individuals with disabilities overlap with all these groups. But they also have distinct needs with material implications for the organization, delivery, and financing of health care services. Despite the disproportionate health care needs and expenditures of many--though not all--individuals with disabilities, the mainstream health services research community has largely neglected them. This article outlines the most pressing health service research issues in addressing the health care needs of individuals with disabilities.

Adult↗

Postmodern personhood: a matter of consciousness.

The concept of person is integral to bioethical discourse because persons are the proper subject of the moral domain. Nevertheless, the concept of person has played no role in the prevailing formulation of human death because of a purported lack of consensus concerning the essential attributes of a person. Beginning with John Locke's fundamental proposition that person is a 'forensic term', I argue that in Western society we do have a consensus on at least one necessary condition for personhood, and that is the capacity for conscious experience. When we consider the whole brain formulation of death, and the most prominent defense of it by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, we can readily identify the flaws that grow out of the failure to define human death as the permanent loss of the capacity for conscious experience. Most fundamental among these flaws is a definition of human death that reduces persons to the capacity of the brain to regulate purely physiological functioning. Such a formulation would, in theory, apply to any member of the animal kingdom. I suggest that an appropriate concept of death should capture what it is about a particular living being that is so essential to it that the permanent loss of that thing constitutes death. What is essential to being a human being is living the life of a person, which derives from the capacity for conscious experience.

Advisory Committees↗

Response of low income women and abortion facilities to restriction of public funds for abortion: a study of a large metropolitan area.

During the first five months after the restriction of public funds for abortion, a large percentage of low-income women seeking abortions in a metropolitan area in Texas obtained abortion that were partially subsizied using a combination of reduced clinic fees and public funds for ancillary non-abortion services. Their own personal funds made up the difference between the subsidy and the full cost of the procedure.

Abortion, Induced↗

Persistence in health expenditures in the short run: prevalence and consequences.

BACKGROUND: Knowing whether persons in the top percentiles of the health expenditure distribution exhibit persistently high expenditure is fundamental to developing health plan payment policies, containing costs, and understanding the consequences of costly illnesses. OBJECTIVES: To determine the extent of high expenditure persistence over a 2-year period. To identify the correlates and consequences of expenditure persistence. SUBJECTS: A national sample of the population from a longitudinal panel of the Medical Expenditure Panel Survey (MEPS). METHODS: Changes in a person's position in the expenditure distribution were examined. chi2 tests were used to identify differences in characteristics between high and low spenders. Logistic regression was used to predict the likelihood of expenditure persistence. Changes in income, employment, out-of-pocket expenditure burden, and health insurance were compared for high and low spenders. RESULTS: Of the top 5% of spenders in 1996, 30% retain this position in 1997 and 45% are in the top decile of 1997 spenders. High expenditures begin to regress to the mean over the study period. Cancer, mental disorders, diabetes, and infectious diseases and being in the top decile of 1996 spenders increase the probability of expenditure persistence (P < 0.05 for all). This probability also has a strong random component. An increased proportion of persons in the top expenditure decile for both years had out-of-pocket health spending greater than 20% of income in 1997 (P < 0.10). Persons with persistently high expenditures were less likely than low spenders to lose employment-based coverage (5.4% vs. 8.8%, P < 0.05) but no changes in income or employment status were detected. CONCLUSIONS: A sizable minority of persons exhibits persistently high expenditures, creating incentives for favorable risk selection. Few consequences of short-run expenditures persistence are observed.

Adult↗

The looming retirement crisis.

A retirement crisis looms in the United States due to a number of recent and emerging trends that affect government retirement programs, employer- and union-sponsored retirement benefits and personal savings arrangements. The crisis can be averted, but only with well-thought-out action on a number of issues, particularly Social Security and Medicare reform.

Financing, Personal↗

The cost of prenatal care attendance and pregnancy outcomes in low-income working women.

OBJECTIVE: To examine personal costs (dollar costs and time spent) associated with prenatal care (PNC) attendance and outcomes (gestation length, PNC adequacy, and birth weight) for low-income, working women (N = 165). DESIGN: Prospective, descriptive study. SETTING: Participants were recruited from a pre-natal clinic located at an inner city tertiary care center. PARTICIPANTS: A convenience sample of 165 low-income, working women. MAIN OUTCOME MEASURES: Personal costs were measured as dollar costs and time spent associated with PNC attendance. Perinatal outcomes were measured as gestation length, PNC adequacy, and birth weight. RESULTS: Per visit, the mean cost associated with PNC was 33.31 dollars (range 1-125.60 dollars, SD = 32.33 dollars) and the time needed to attend care was 228 min (20-720, SD = 205). Women delivered at 37.8 (18-42) weeks; 17.6% of the women received inadequate PNC, and 17.0% of the women delivered low-birth-weight newborns. CONCLUSIONS: The findings indicated that personal costs associated with PNC attendance were not associated with inadequate care attendance.

Absenteeism↗

Good managed care needs universal health insurance.

Although the increase of corporate managed care has helped to reduce excesses and costs, continued gains in cost-effectiveness depend on good clinically managed care. Benefits of clinically managed care depend on stable contracts and universal coverage. Instead, employers are decreasing coverage and creating a market of "lemons" in which low-cost plans are rewarded for cost-cutting tactics. These tactics have spawned movements that demand rights for patients and providers. Choosing to shore up those rights, however, will increase the number of uninsured persons. This tragic choice, which no other industrialized nation has permitted, will not be resolved until some form of universal health insurance is implemented.

Cost Control↗

Congress advances on health care reform: one step at a time.

In adopting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress made a series of small but significant steps toward improving access to health care benefits. The Act's centerpiece is its new requirements for group health plans and for the health insurance industry for assuring portability, access, and renewability of health insurance coverage. Of nearly equal importance is the pilot program established for testing the viability of medical savings accounts. Other health-related changes include adjustments in the rules governing duplication and coordinating of Medicare-related plans, recommendations with respect to privacy of health information of employees, an increase in the deduction for health insurance costs for self-employed individuals, and permission for unemployed persons to make withdrawals from IRAs and other qualified plans for certain medical services' costs. This article summarizes these and other key provisions of HIPAA.

Cost Sharing↗

The interests of three stakeholders in independent personal care for disabled elders.

There is concern throughout developed countries about how sufficient services can be mounted in this century to care for all older, disabled persons who want to remain at home. With declining availability of family care and high turnover among paid workers, cost, care supply, and quality dilemmas abound. Therefore, how can home care be improved? One suggestion is to revise the care "contract" by simply eliminating the costly bureaucratic and controlling dimensions of agency oversight and management. In consumer-directed or self-managed care, independent workers are hired directly by consumers or their family members. Consumers spend their own private money or government provides authorization for them to "hire" their own workers. Such arrangements may be more responsive to the needs of consumers, more directly accountable to them, and less costly for both individuals and government. This article examines 41 cases of consumer-directed care in Milwaukee. Extended interviews with three "stakeholders" in care--the disabled, older client, the family caregiver, and the personal assistant--were conducted, including both private pay and government subsidized arrangements. This analysis identifies some essential, but disparate interests of the three partners in care.

Aged↗

[A dilemma--public health care].

The financing of personal health care services has become the crucible to test elected governments in the 21st century. Governments are caught between slow economic growth, lower personal income for most workers, and the clamour of health care for more money. The Western world with an aging population, marginal employment and rising unemployment, does not appear to have the capacity to pay for all that science and technology can produce and the public wants. Neither private nor public financing seem to have developed the machinery to identify need, and to balance demand with national economic output. I wish to suggest, that although the countries in the industrialised world have travelled different routes we have arrived at the same place. The art and science of medicine coupled with the human quest for health may simply exceed our productive capacity. The organisation and financing of twenty-First Century science and technology is nearly dysfunctional, bound by Nineteenth Century values, traditions and custom, as we face the next century. This may be the question.

Cost Control↗

[Out-of-pocket medical spending for care in patients with recent onset rheumatoid arthritis].

We examined out-of-pocket medical expenditures (OoP) of 869 patients with recent onset rheumatoid arthritis (ACR criteria, disease duration <2 years) using data from a prospective observational cohort. Out-of-pocket costs were retrospectively assessed for a period of 6 months by a list of 14 cost domains. Of the patients, 82% had costs due to copayments for prescribed drugs and 56% for over-the-counter drugs. Within six months each patient spent an average of 47 (+/- 67) Euro as co-payment and 45 (+/- 96) Euro for over-the-counter drugs. A comparable sum was spent for complementary and alternative medicine (47+/-250 Euro), which was used by 14% of the patients. The mean total OoP expenditure caused by RA was 628 Euro p.a. (median 306, IQ 66-334 Euro). The median costs accounted for approximately 2% of the average disposable yearly income in Germany. Out-of-pocket spending increased with functional limitations, poor health condition and pain as well as with level of education. A multivariate logistical regression analysis showed that patients with these characteristics spent about twice as much as patients with mild disease or low educational level. The odds ratios for having more than 306 Euro OoP-costs p.a. were OR=2.6 (CI 1.7-4) for patients with severe vs. moderate functional disability (HAQ> or =1.5 vs <1.5), OR=2.4 (CI 1.4-4.4) for patients in poor vs. good health condition (NRS 7-10 vs 0-3), and OR=2.1 for patients with severe vs. mild pain (CI 1.4-3.3). The level of OoP spending also varied by employment status (OR=0.28; CI 0.1-0.6 for jobless vs employed patients). Despite almost universal insurance coverage in Germany, patients with rheumatoid arthritis were exposed to substantial OoP expenditures. As policymakers discuss cost sharing and design of benefit packages to contain health spending, it is important to consider the expenditures that persons with chronic conditions like rheumatoid arthritis already have.

Activities of Daily Living↗

Drug coverage and drug purchases by Medicare beneficiaries with hypertension.

Research has shown that older Americans with prescription drug coverage purchase more medications; however, it is unclear whether they are more likely to purchase essential medications. This study addresses that question by examining the relationship between drug coverage and medication purchases among older Americans with hypertension. It finds that drug coverage has a significant impact: It lowers the likelihood that persons with hypertension will go without antihypertensive drugs, and it raises the number of tablets purchased among those who purchase these essential drugs.

Aged↗

Integrating benefits decision making.

Integrated employee benefit decision making helps employees use their benefits more wisely and identify opportunities to balance their immediate benefits needs (such as health care) and future benefits needs (such as retirement). This article discusses how employers can overcome employees' behavioral barriers to making integrated employee benefit decisions by changing the ways benefits are communicated and employees are presented with action decisions. Undertaking these steps allows employers to not only improve their employees' overall financial perspectives, but also furthers plan sponsors' goals of actively promoting personal responsibility with respect to retirement funding and changing employee behavior with respect to controlling health care costs.

Choice Behavior↗