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PubMed2006

Community-level uninsurance and the unmet medical needs of insured and uninsured adults.

OBJECTIVE: To examine the relationship between community-level uninsurance rates and the self-reported unmet medical needs of insured and uninsured adults in the U.S. DATA SOURCES: 2000-2001 Community Tracking Study, which includes data from 60 randomly selected U.S. communities. The sample is representative of the contiguous U.S. states. STUDY DESIGN: Multilevel logistic regressions were employed to investigate whether the local uninsurance rate was related to having reported unmet medical needs within the last year. The models also included individual and community variables that could be potentially related to both community uninsurance rates and having reported unmet medical needs. PRINCIPAL FINDINGS: The community uninsurance rate was positively associated with having reported unmet medical needs, but only for insured adults. On average, a five percentage point increment in the local uninsured population is associated with a 10.5 percent increase in the likelihood that an insured adult will report having unmet medical needs during the 12-month period studied. CONCLUSION: Local health care delivery systems seem to be negatively affected by high uninsurance rates. These effects could have negative consequences for health care access, even for individuals who are themselves insured.

Adult↗
PubMed2005

Employment-based health insurance: analysis of rural-urban differences in one state.

This study estimates the propensity of firms to offer health insurance in a simultaneous equation model to control for the endogeneity between wages and health insurance. Previous research finds differences in rural and urban employer behavior with respect to health insurance benefits fully explained by differences in wages and firm size. In contrast, this study finds residual unexplained differences in the propensity to offer coverage that may be attributable to differences in plan supply, plan distribution, or differences in availability of substitutes for coverage (safety net care). Rural worker participation in offered coverage is more responsive to wage level than is the participation decision of urban workers. Together, these results imply that some of the differences in health insurance coverage rates for rural workers could be amenable to policy interventions.

Adult↗
PubMed1995

The impact of German health insurance reforms on redistribution and the culture of solidarity.

The statutory health care scheme represents the most ambitious branch of the German social insurance system because it entails interpersonal redistribution on a large scale. The stability of this centerpiece of the German welfare state thus depends on a "culture of solidarity" to maintain the legitimacy of these redistributions. In this article, the present debate on restructuring the welfare state in general is analyzed. However, the focus is on the ongoing struggle to further reform the health care system. Influential political actors proposals to depart from universal access to a comprehensive range of health care benefits based solely on medical need and from the earnings-related mode of financing stand in stark contrast to empirical results on insured persons' willingness to support the existing system. Findings from qualitative interviews show that a culture of solidarity still prevails among insured persons. It is argued that lasting political attempts to shift the balance between solidarity and self-reliance in favor of the latter could weaken this moral infrastructure of the welfare state and, as a consequence, the statutory health insurance system could lose its plausibility and attraction. Such a development would ease the reconstruction of the social security system by privatizing parts of currently public expenditures and reducing the scope of interpersonal redistribution.

Consumer Behavior↗
PubMed1996

Income, health status, and insurance coverage of small group employees in a voluntary purchasing arrangement.

The ongoing health care reform discussion has highlighted the problems of insuring small group employees. Several state and private initiatives have attempted to address some of these problems through the formation of voluntary small group purchasing arrangements. This article uses data from one such initiative, Health Care Group of Arizona (HCGA), to describe the income, health status, and prior insurance of small group employees who enrolled in prepaid health plans through HCGA. It also compares employee enrollees to nonenrollees along these dimensions. The findings suggest that HCGA enrollees had relatively low incomes and that about three-quarters were without health insurance prior to enrollment. Higher income employee enrollees were more likely to report health conditions at enrollment even after controlling for other factors including age. Enrollees were less likely than nonenrollees to have prior health insurance but were more likely to be drawn from lower income groups and to report recent health conditions.

Adolescent↗
PubMed1999

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↗
PubMed1992

Employer-sponsored health insurance in 1991.

Since 1987 the Health Insurance Association of America (HIAA) has documented features of employer-sponsored group health insurance through detailed surveys of over 3,000 U.S. firms. The 1991 employer survey reveals several noteworthy developments. The percentage of small firms (100 employees and under) that offer health insurance to their employees has declined since 1989. With a significant increase in health maintenance organization (HMO) market share, more than half (54 percent) of employees in employer-sponsored plans are now covered by managed care plans. Premiums increased 14 percent in 1991, showing identical increases for conventional, HMO, and preferred provider organization (PPO) plans. The percentage of employees in self-insured health plans decreased from 45 percent in 1990 to 40 percent in 1991.

Cost Control↗
PubMedDate not supplied

Employment-based health insurance: past, present, and future.

We review the rise, stabilization, and decline of employment-based insurance; discuss its transformation from quasi-social insurance to a system based on actuarial principles; and suggest that the presence of Medicare and Medicaid has weakened political pressure for universal coverage. We highlight employment-based insurance's flaws: high administrative costs, inequitable sharing of costs, inability to cover large segments of the population, contribution to labor-management strife, and the inability of employers to act collectively to make health care more cost-effective. We conclude with scenarios for possible trajectories: employment-based insurance flourishes, continues to erode, or is replaced by a more comprehensive system.

Cost Allocation↗
PubMed2006

Social insurance and elderly entitlement reform: are they compatible?

There is no inconsistency between Social Security and Medicare reform and a firm commitment to the concept of social insurance. The retirement benefit components of these programs are not part of social insurance. Social insurance allows for people who experience low-probability random bad events to be compensated by others. An event, such as reaching retirement age, is a high-probability event and not a candidate for social insurance.

Aged↗
PubMed1996

Switching Swiss enrollees from indemnity health insurance to managed care: the effect on health status and stisfaction with care.

OBJECTIVES: In 1992, most members of a Swiss indemnity health insurance plan were automatically transferred into a newly created managed care organization. This study examined whether this semivoluntary change affected enrollees' health status and satisfaction with care. METHODS: Three groups of enrollees were compared: 332 plan members who accepted the switch (managed care joiners); 186 plan members who opted to maintain indemnity coverage (non-joiners); and 296 persons continuosly enrolled in another indemnity plan (indemnity plan members). Health status, health related behaviors, and satisfaction with care received in the previous year were surveyed at baseline and 1 year later. RESULTS: Health status remained unchanged in all three groups. Smoking prevalence decreased among managed care joiners but remained constant in the other groups. Satisfaction with insurance coverage increased between baseline and follow-up in managed care joiners, but decreased in nonjoiners and indemnity plan members. The latter groups had higher satisfaction with health care, particularly with continuity of care. CONCLUSIONS: A semivoluntary switch from indemnity health insurance to managed care reduced satisfaction with health care but increased satisfaction with insurance coverage. There were no changes in self-perceived health status.

Adult↗
PubMed1997

Health insurance coverage among foreign-born US residents: the impact of race, ethnicity, and length of residence.

OBJECTIVES: This study examined the health insurance status of the US foreign-born population and the influence of race, ethnicity, and length of residence on health insurance status. METHODS: Data were obtained from the 1989 and 1990 National Health Interview Surveys, including the Insurance and Family Resource Supplements. RESULTS: In 1989 and 1990, the foreign-born population was twice as likely as the US-born population to be uninsured (26.2% vs 13.0%). The highest rate of uninsured status, 40.8%, was found among foreign-born Hispanics. Persons who had lived in the United States for less than 15 years were 1.5 to 4.7 times more likely to be uninsured than were US-born Whites. CONCLUSIONS: Foreign-born US residents-especially Hispanics and persons residing in the United States for less than 15 years-are vulnerable to not having health insurance, which may limit their access to medical services. The administrative criteria for public programs may explain the high rates of uninsured status among recent immigrants. Recently enacted federal legislation could substantially increase the number of uninsured among the US foreign-born population, with profound public health implications.

Adolescent↗
PubMed2004

A study on a reduction in visits to physicians after introduction of 30% co-payments in the employee health insurance in Japan.

The purpose of the study is to evaluate influences of the introduction of 30% co-payments on potential visit behavior using a questionnaire in order to determine whether "employment state of the spouse" and "number of dependent children", as indicators of economic backgrounds, affect visits to physicians in a health insurance society. The subjects were 1,674 insured consisting of 1,165 males and 509 females, who underwent a regular health examination in July 2002, in a health insurance society. In the survey, they were asked whether the subject "will reduce" or "will not reduce" visits to physicians due to the increase in co-payments in the health insurance system scheduled in 2003. Multivariate analyses showed that "employment state of the spouse" was significantly related to the reduction in visits for myocardial infarction or stroke, cancer or heart disease, and hypertension and diabetes mellitus. Concerning "number of dependent children", it was related to the risk of reducing visits to physicians for myocardial infarction or stroke, trauma or fracture, cancer or heart disease, and low back pain or knee pain. Finally, upper limit expenditures of co-payments of physicians to visits due to hypertension and diabetes mellitus were related to "number of dependent children". The study results suggest that "employment state of the spouse" and "number of dependent children" are significant factors to affect potential visits to physicians after the introduction of 30% co-payments.

Adult↗
PubMed2005

The effect of SCHIP expansions on health insurance decisions by employers.

This study uses repeated cross-sectional data from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC), a large nationally representative survey of establishments, to investigate the effect of the State Children's Health Insurance Program (SCHIP) on health insurance decisions by employers. The data span the years 1997 to 2001, the period when states were implementing SCHIP. We exploit cross-state variation in the timing of SCHIP implementation and the extent to which the program increased eligibility for public insurance. We find evidence suggesting that employers whose workers were likely to have been affected by these expansions reacted by raising employee contributions for family coverage options, and that take-up of any coverage, generally, and family coverage, specifically, dropped in these establishments. We find no evidence that employers stopped offering single or family coverage outright.

Adolescent↗
PubMed2001

Long-term care insurance and integrated care for the aged in Japan.

By the introduction of a public, mandatory program of Long-Term Care Insurance (LTCI) on April 1, 2000, Japan has moved towards a system of social care for the frail and elderly. The program covers care that is both home-based and institutional. Fifty percent of the insurance is financed from the general tax and the other fifty percent from the premiums of the insured. The eligibility process begins with the individual or his/her family applying to the insurer (usually municipal government). A two-step assessment process to determine the limit of benefit follows this. The first step is an on-site assessment using a standardised questionnaire comprising 85 items. These items are analysed by an official computer program in order to determine either the applicant's eligibility or not. If the applicant is eligible it determines which of 6 levels of dependency is applicable. The Japanese LTCI scheme has thus formalised the care management process. A care manager is entrusted with the entire responsibility of planning all care and services for individual clients. The introduction of LTCI is introducing two fundamental structural changes in the Japanese health system; the development of an Integrated Delivery System (IDS) and greater informatisation of the health system.

Journal Article↗
PubMed1982

Medical ramifications of the federal regulation of the Social Security Disability Insurance program: Social Security and medicine.

Social Security Disability Insurance is a federally created and regulated insurance plan. The definition of disability as it relates to work capacity is exclusively the purview of government administrators. The primary physician's opinion has little, it any, impact on decision. Administering this insurance scheme requires the quantification of illness as it relates to work capacity (disability). What has evolved is a program that insures for the amount of "disease." The assumption is that with more disease, there is a greater likelihood of illness, even illness manifest as work incapacity. Leaving this underlying assumption tacit is responsible for the adversary climate that envelops the physician, the patient-claimant, and the administrators. It is also responsible for the paucity of clinical investigations into the critical issue of the amount and form of illness a diseased person will have.

Arthritis, Rheumatoid↗
PubMed1999

[The "cost reimbursement" trial regulation in mandatory health insurance: results of a survey of participants].

Since 1994 seven substitution funds of the German statutory health insurance have offered their mandatorily insured members to choose cost reimbursement in place of benefits in kind for a limited testing period. Participants of the cost reimbursement arrangement are considered private patients and are billed accordingly. However, these bills are only in part reimbursed. This study investigates the expectations participants had with respect to the cost reimbursement arrangement as well as the experiences they made. For this purpose a survey among the participants was carried out using a self-administered questionnaire. Most of the 1390 respondents were satisfied with the cost reimbursement arrangement. Organisational, personal and medical advantages which the majority of participants expected were mostly fulfilled. Especially elderly members chose the cost reimbursement arrangement and often made the experience that their doctors spent more time talking to them. The necessary co-payments had hardly any impact on the positive judgment; most participants had an extra private insurance to close the gap of coverage. The results also show that transparency, control of costs and cost-consciousness of patients are improved by the cost reimbursement method. With respect to the preferences of the insured, the results of this study plead for keeping up the offer of cost reimbursement as an alternative to benefits in kind. However, the influence of sickness funds on the care process as well as the equity of care may be negatively affected.

Adult↗
PubMed1995

The health insurance system in Korea and its implications.

The national health insurance system was introduced in Korea in 1977 and achieved universal coverage in July 1989. This article briefly describes the general features of the insurance scheme: coverage, management, benefit package, financing provision of medical services and method of reimbursement. Generally speaking, the system mirrors that of the German and Japanese experiences. Although the Korean health insurance system achieved universal coverage during a remarkably short time-span, there is much room for improvement. In this regard, the article also highlights the problems related to Korea's health insurance system and the attempts to improve equity and efficiency in both financing and provision of services.

Cost-Benefit Analysis↗
PubMed1992

The effect of the Americans With Disabilities Act upon medical insurance and employee benefits.

The Americans With Disabilities Act will have a significant impact upon plan sponsors and the administration of an employee benefit plan. Prior to the July 26, 1992 effective date, a plan sponsor or trustee should meet with the plan's attorney, provider and other insurance advisers and review the effect ADA will have upon the plan. The EEOC will be issuing additional interpretive rules before the effective date of ADA, and there will be numerous court challenges after the effective date. Plan sponsors and trustees should keep abreast of the developments as they occur. Before a benefit change or premium adjustment is made, it should be reviewed with legal counsel to assure that it conforms to ADA's insurance exemption. Plan sponsors and trustees should have legal counsel, the provider and the plan's insurance advisers develop the documentation that will enable the plan to establish ADA's insurance exemption to defend any legal challenge.

Civil Rights↗
PubMed1999

Development of State Health Insurance System in Georgia.

Since 1994, health resources in Georgia have became insufficient. The spending for the health care services per person in 1985 were US$95. 5, US$12.2 in 1989, and US$0.9 in 1994. Currently there are 58.5 physicians per 10,000 inhabitants. The birth rate decreased from 16. 7 in 1989 to 11 in 1997. The mortality rate of pregnant women due to extragenital pathologies, iron deficiency anemias (40% of the total pregnant women), iodine deficiency and complicated abortions are also on the increase. The State Parliament of Georgia decided to reorganize the health care system and, in August 1995, State Health Care Programs and the new system of reimbursement of providers were launched. The monthly contribution rate of medical insurance, which was 4% of the payroll (3% paid by the employer and 1% by the employee), is transferred from the Central Budget directly to the State Medical Insurance Company, which implements nine State Curative Programs. State medical insurance system co-exists with municipal and private health care. Municipal health coverage is closest to the universal coverage (over 80% of the population), and municipal health care services are the closest to a basic package of services satisfying most health care needs of the population. The exceptions are pregnant women and mothers and children under 1 year of age, who are covered by the Federal Programs under State Medical Insurance.

Georgia (Republic)↗

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