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Changing the method for calculating quarters of coverage: the impact on workers' insured status.

The 1977 Social Security Amendments specified that, beginning in 1978, a worker would be credited with one quarter of coverage for a designated amount of annual earnings. For 1978, a worker received one quarter of coverage (up to a total of four) for each $250 in annual earnings from employment or self-employment. Before 1978, a worker who was paid $50 in wages in a calendar quarter was credited with a quarter of coverage. A person who had $400 or more in self-employment income in a year was credited with four quarters of coverage. Some workers received more quarters of coverage under the new provisions than they would have under the old, and other workers received less. Since a worker's receipt of benefits depends on his or her insured status, which is based on quarters of coverage, this change can affect a worker's eligibility for benefits. This study indicates that if $250 in annual earnings had been required for one quarter of coverage in 1977, more than 2.1 million workers would have had a change in their insured status for disabled worker benefits, and about 700,000 workers would have had a change in their insured status for survivor benefits. Those whose insured status was affected were most likely to have had marginal earnings records--for example, they had four to seven quarters of coverage when six were needed. (This effect was expected when the legislation was passed.) This article examines those whose eligibility for benefits was most likely to have been affected.

Adolescent↗

Improving vaccination coverage: the experience of the Expanded Programme on Immunization in Vanuatu.

This paper looks at the success of measures adopted to improve vaccination coverage of infants in the Republic of Vanuatu. In 1982 the Department of Health introduced an Expanded Programme on Immunization (EPI). Since the republic has over 80 inhabited islands, a scattered population, rough terrain and a lack of transport and communications infrastructure, achieving a high vaccination coverage rate proved difficult. Coverage of infants remained low until 1987. From that year onwards various strategies were employed to increase coverage, including 1) adopting the WHO-recommended diphtheria-pertussis-tetanus (DPT) and oral polio vaccine (OPV) vaccination schedule (6, 10 and 14 weeks) instead of the former schedule (3, 6 and 9 months); 2) improving the training, support and supervision of staff delivering maternal and child health (MCH) services; and 3) improving community involvement through social mobilization activities in areas of low coverage. Data on vaccination coverage of infants for the period 1984 to 1990 were compared. Over this period coverage of infants with 3 doses of DPT rose from 29% to 76%, with 3 doses of OPV from 29% to 78%, and with measles vaccine from 19% to 66%. These dramatic improvements have largely occurred since 1987. The results demonstrate the success of the measures adopted, and the experience of Vanuatu offers lessons in improving vaccination coverage for other countries in the region.

Community Participation↗

[The vaccination coverage in a cohort of children at 2 years of age from a health area].

OBJECTIVES: To estimate the vaccination coverage of two-years-old children in the health district of Gijón (Spain), the number of incomplete vaccinations and their causes. To evaluate the vaccination registry coverage. DESIGN: Descriptive cross-sectional survey. SITE. Primary health care. PATIENTS: From the cohort born in 1989, living in the health district, a sample of 219 children was taken. Of these, criteria for inclusion in the study were met by 199 (90.8%), and the vaccination status was ascertained in 191 (87.2%). MAIN MEASUREMENTS AND RESULTS: The variables related with the vaccination coverage were studied through registrations or specific questionnaires. The full vaccination coverage with 3 doses of DTP, 1 dose of DT, 4 doses of VPO and one dose of MMR in the district was 92.5%. Estimating vaccination coverage using only our public registration systems, would lower it to 84.9. This result suggest that the public sector vaccination registry in Gijón under-registers immunizations. Vaccination coverage was 99.5% for first dose (3 months: DTP and VPO) and 93.5% for last doses (18 months: DT and VPO). For MMR it was 94.5%. CONCLUSIONS: Our data suggests there is a high vaccination coverage in the Gijón area. We consider population's questionnaires a satisfactory way to estimate vaccination coverage, and besides to evaluate the validity of the usual registers to use them as information resource.

Chi-Square Distribution↗

Evaluation of immunization coverage by lot quality assurance sampling compared with 30-cluster sampling in a primary health centre in India.

The immunization coverage of infants, children and women residing in a primary health centre (PHC) area in Rajasthan was evaluated both by lot quality assurance sampling (LQAS) and by the 30-cluster sampling method recommended by WHO's Expanded Programme on Immunization (EPI). The LQAS survey was used to classify 27 mutually exclusive subunits of the population, defined as residents in health subcentre areas, on the basis of acceptable or unacceptable levels of immunization coverage among infants and their mothers. The LQAS results from the 27 subcentres were also combined to obtain an overall estimate of coverage for the entire population of the primary health centre, and these results were compared with the EPI cluster survey results. The LQAS survey did not identify any subcentre with a level of immunization among infants high enough to be classified as acceptable; only three subcentres were classified as having acceptable levels of tetanus toxoid (TT) coverage among women. The estimated overall coverage in the PHC population from the combined LQAS results showed that a quarter of the infants were immunized appropriately for their ages and that 46% of their mothers had been adequately immunized with TT. Although the age groups and the periods of time during which the children were immunized differed for the LQAS and EPI survey populations, the characteristics of the mothers were largely similar. About 57% (95% CI, 46-67) of them were found to be fully immunized with TT by 30-cluster sampling, compared with 46% (95% CI, 41-51) by stratified random sampling. The difference was not statistically significant. The field work to collect LQAS data took about three times longer, and cost 60% more than the EPI survey. The apparently homogeneous and low level of immunization coverage in the 27 subcentres makes this an impractical situation in which to apply LQAS, and the results obtained were therefore not particularly useful. However, if LQAS had been applied by local staff in an area with overall high coverage and population subunits with heterogeneous coverage, the method would have been less costly and should have produced useful results.

Adult↗

The effect of health insurance coverage on the appropriate use of recommended clinical preventive services.

INTRODUCTION: Lack of health insurance coverage has been shown to reduce use of some preventive services. However, even when care is free or fully covered by insurance, clinical preventive services are not used at recommended levels. This study investigates the impact of different levels of health insurance coverage (ranging from none, some, most, and all preventive services covered) on the use of recommended clinical preventive services for adult men and women. METHODS: Logistic regression was used to estimate the effect of different levels of health insurance coverage for preventive care on the probability of receiving six different clinical preventive services including periodic health exam, blood pressure screening, cholesterol screening, Pap smear, clinical breast exam, and screening mammography, as well as all recommended services for a given age and gender group. The study sample of adults ages 18 to 64 is from the Centers for Disease Control's 1991 Behavioral Risk Factor Surveillance System (BRFSS) (n = 53,981). RESULTS: The results demonstrate a positive and statistically significant dose-response relationship between level of health insurance coverage for preventive care and receipt of recommended preventive services in adult men and women. The odds ratios (ORs) of men who had full coverage for preventive care receiving recommended preventive services compared to men with no coverage for preventive care ranged from 1.8 to 2.8. For women the ORs were 1.2 to 2.0. The ORs for men with "most" preventive services covered compared to none covered ranged from 1.3 to 2.1, and for women from 1.2 to 2.0. CONCLUSIONS: The level of health insurance coverage for preventive care is one of the most important determinants of receipt of recommended preventive services for adult men and women 18-64 years of age. These results suggest that comprehensive health insurance coverage for clinical preventive care may significantly increase receipt of recommended preventive services for this population.

Adolescent↗

Self-assessed health status and selected behavioral risk factors among persons with and without health-care coverage--United States, 1994-1995.

Persons without health-care coverage are more likely to have poor health and be at greater risk for chronic disease outcomes than persons who have health-care coverage. In the United States, the number of persons and the proportion of the population without health-care coverage has increased each year since 1987. State-specific surveillance of health-care coverage can be used to identify subgroups of the population who lack such coverage and may be at increased risk for poor health. To determine state-specific estimates of the prevalence of self-assessed health status and risk factors for chronic disease by health-care coverage status among adults aged 18-64 years, CDC analyzed data from the 1994 and 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis and indicates that adults without health-care coverage were more likely than those with health-care coverage to have poor health status, to be current smokers, and to be less physically active.

Adult↗

[The coverage of vaccines systematically administered and of a vaccine against Haemophilus influenzae type b prior to its inclusion in the vaccinal calendar in the Valencian Community].

OBJECTIVE: The objective of this study was to estimate the vaccine coverage among children two years of age in the Community of Valencia, Spain, in 1997. PATIENTS AND METHODS: Cluster sampling was used to assess vaccine coverage. Clusters were villages randomized according to their population < 5 years of age. At least 7 children of each of the 30 selected clusters were randomly selected from the database of newborn metabolic screening. Parents were contacted and vaccine registration cards requested by mail. RESULTS: Four hundred forty subjects were selected. Eight percent of the families had moved and were not contacted. Sixty-nine percent participated in the study. Coverage for three doses of DTP was 97.8% and 87.6% for four doses. MMR vaccine coverage was 96.6% and three doses of hepatitis B had been given in 95.1%. H. influenzae type b (Hib) vaccine coverage was 57%. In 70% of the studied cases of non-participants, vaccine coverage was known through vaccination centers and was very similar to that of the participants. CONCLUSIONS: Vaccine coverage in the Community of Valencia is high for the scheduled vaccines. Although Hib is not a scheduled vaccination, its coverage was 57%.

Chi-Square Distribution↗

Expanding insurance coverage through tax credits, consumer choice, and market enhancements: the American Medical Association proposal for health insurance reform.

Recent reports showing an increase in the number of uninsured individuals in the United States have given heightened attention to increasing health insurance coverage. The American Medical Association (AMA) has proposed a system of tax credits for the purchase of individually owned health insurance and enhancements to individual and group health insurance markets as a means of expanding coverage. Individually owned insurance would enable people to maintain coverage without disruption to existing patient-physician relationships, regardless of changes in employers or in work status. The AMA's plan would empower individuals to choose their health plan and give patients and their physicians more control over health care choices. Employers could continue to offer employment-based coverage, but employees would not be limited to the health plans offered by their employer. With a tax credit large enough to make coverage affordable and the ability to choose their own coverage, consumers would dramatically transform the individual and group health insurance markets. Health insurers would respond to the demands of individual consumers and be more cautious about increasing premiums. Insurers would also tailor benefit packages and develop new forms of coverage to better match the preferences of individuals and families. The AMA supports the development of new health insurance markets through legislative and regulatory changes to foster a wider array of high-quality, affordable plans.

American Medical Association↗

Health insurance coverage of the unemployed: COBRA and the potential effects of Kassebaum-Kennedy.

We use the April 1993 Current Population Survey to examine the health insurance coverage decisions of the unemployed and to simulate the potential effects of the new Kassebaum-Kennedy legislation. After controlling for demographic characteristics, COBRA eligibility raises the probability of health insurance coverage by 0.095, while eligibility for spouse employer insurance increases the likelihood of coverage by 0.318, and eligibility for both increases the likelihood of coverage by 0.341. In our simulations, we find that had Kassebaum-Kennedy been in effect in April 1993, 9.0 percent of the unemployed would be eligible to take up coverage, and the coverage rate of the unemployed would have been increased by 0.85 percent to 1.5 percent from 41.6 percent. Our estimates of the effect of Kassebaum-Kennedy on health insurance coverage are much lower than those reported by the Government Accounting Office prior to the passage of the legislation.

Eligibility Determination↗

The impact of the tax system on health insurance coverage.

A central question in health economics is the extent to which this tax subsidization matters for the health insurance coverage of the U.S. population. I assess the impact of taxes on health insurance by using the considerable existing variation in tax subsidies, both at a point in time and across time. I do so by putting together data from more than a decade of Current Population Survey (CPS) data sets, and matching to workers in those data sets their tax subsidies to health insurance coverage. I find that the elasticity of insurance eligibility of workers is at least -0.6, and that the elasticity of own insurance coverage is roughly similar; the results imply that most of the impact of taxes on insurance coverage arise through firm offering and eligibility decisions. I also find that higher tax rates induce more private coverage through other sources, but less public coverage, so that overall there is a reduction in the rate of uninsurance that is comparable to the change in own employer-provided insurance coverage.

Adult↗

Children in the United States with discontinuous health insurance coverage.

BACKGROUND: Estimates of the number of uninsured people in the United States usually exclude those with discontinuous coverage. The effects of gaps in insurance coverage for children on access to and use of ambulatory care are poorly understood. METHODS: We analyzed a sample of 26,955 children under 18 years of age from the 2000 and 2001 National Health Interview Surveys. Children with discontinuous health insurance coverage were compared with those who were uninsured all year and with those who had public or private full-year coverage. RESULTS: During the last 12 months before they were interviewed, 6.6 percent of children in the United States had no insurance and an additional 7.7 percent had gaps in insurance. Children who had full-year insurance coverage (private or public) had low rates of unmet health care needs and good access to care (delayed care, unmet medical care, and unfilled prescriptions were reported in <3 percent, and <5 percent had no usual place of care). Access to care was much worse for children who were uninsured for part of the year and for those who were uninsured for the full year (delayed care, 20.2 percent and 15.9 percent, respectively; unmet medical care, 13.4 percent and 12.6 percent, respectively; unfilled prescriptions, 9.9 percent and 10.0 percent, respectively; P<0.01 for all comparisons with children with full-year, private insurance coverage). In multivariate analyses adjusting for age, income, race or ethnic group, region, citizenship, family structure, parental employment, and health status, the differences in access to care persisted. As compared with the parents of children with full-year, private insurance, parents of children uninsured for the full year were far more likely to report delaying care (adjusted odds ratio, 12.65; 95 percent confidence interval, 9.45 to 16.94), as were parents of children uninsured for part of the year (adjusted odds ratio, 13.65; 95 percent confidence interval, 10.41 to 17.90). CONCLUSIONS: Children with gaps in health insurance coverage commonly do not seek medical care, including preventive visits, and do not get prescriptions filled. These findings are important for both research and policy and point to the need for more encompassing and sensitive measures of the situation of being uninsured.

Adolescent↗

The association between health care coverage and the use of cancer screening tests. Results from the 1992 National Health Interview Survey.

OBJECTIVES: The authors investigated whether utilization of six different cancer screening tests (mammography, clinical breast exam, Pap smear, Fecal Occult Blood Test, and Digital rectal exam) varied according to type of health care coverage. METHODS: Data on the use of cancer screening tests and coverage in two age groups from a 1992 nationally representative cross-sectional survey of approximately 9,400 adults were analyzed. Multiple logistic regression analysis was used to estimate proportions of persons screened according to type and extent of coverage, adjusted for socioeconomic, demographic, and health status characteristics. RESULTS: Persons aged 40 to 64 years with Medicaid coverage were equally as likely to receive five of six cancer screening tests as those with private fee-for-service coverage, and both groups were much more likely to be screened (70% higher for all six tests) than those who had no coverage. In contrast, persons aged 65 years and older who had supplemental private fee-for-service insurance in addition to Medicare were more likely to receive five of six tests than those with Medicare and Medicaid or those with Medicare only. For all six screening tests, managed care enrollees at all ages were approximately 10% more likely to be screened than persons enrolled in private fee-for-service plans. Fecal Occult Blood Test (25% versus 20%) and digital rectal exams (44% versus 38%) in persons aged 40 to 64 years and mammography (59% versus 48%) and Fecal Occult Blood Test screening (38% versus 30%) in the elderly were significantly more frequent for persons in managed care plans. CONCLUSIONS: The extent of fee-for-service insurance coverage in the traditional indemnity US health care system was positively associated with the use of cancer screening tests. The authors found less difference in use of cancer screening between managed care and fee-for-service care in 1992 than we expected based on earlier research comparing use of preventive services in health maintenance organizations with fee-for-service care.

Adolescent↗

Insurance coverage for prescription drugs: effects on use and expenditures in the Medicare population.

BACKGROUND: Although most of the elderly are covered by Medicare, they potentially face large out-of-pocket costs for their health care because of excluded services. Aside from nursing home care, the exclusion of prescription drugs is one of the most significant. Several earlier policy initiatives have proposed adding prescription drug coverage to the Medicare program. To determine the effects of such an expansion, one must account for the potential increase in the demand for prescription drugs from providing insurance coverage. METHODS: The study uses a new data source, the RAND Elderly Health Supplement to the 1990 Panel Study of Income Dynamics (PSID). The endogenity of insurance coverage is tested using instruments that exploit the longitudinal nature of the data. Equations are estimated on 910 persons (> or = 66 years) using a two-part model. RESULTS: Insurance coverage for prescription drugs significantly increases the probability of use, but not of total expenditures, among those who use prescription drugs. However, insurance coverage significantly lowers out-of-pocket expenditures, thereby decreasing the financial burden on elderly households associated with prescription drug use. Medicaid coverage has effects that are smaller than those for private insurance, but the magnitude is less precisely estimated. These findings imply that if prescription drug coverage were added to Medicare, expected expenditures on drugs would rise by on average $83 for each elderly Medicare beneficiary (in 1990 dollars), although this increase is significant only at the 90% level. If the benefit had been included under Medicare, expected spending on prescription drugs by the elderly would have risen by approximately 20%, or $2.6 billion in 1990.

Aged↗

The effects of recent employment changes and premium increases on adults' insurance coverage.

This study uses national survey data from 1997, 1999, and 2002 to estimate a statistical model of the relationships between employment loss, insurance costs, and insurance coverage of nonelderly adults. Simulations based on the model suggest that the large increase in private insurance premiums (about 33 percent in constant dollars) was responsible for 3.1 of the 3.4 percentage-point drop in private insurance coverage between 2000 and 2003. Employment loss has a substantial impact on the coverage of people who lose employment, but its impact on aggregate coverage is relatively small. Expanded public coverage absorbed only about one quarter of the loss of private coverage. Controlling insurance (and medical) cost inflation is critical to expanding insurance coverage, even after the employment rate recovers.

Adult↗

Short-term impacts of coverage loss in a Medicaid population: early results from a prospective cohort study of the Oregon Health Plan.

PURPOSE: Medicaid programs in all 50 states recently implemented cost-saving strategies, including benefit reductions, cost sharing, and tightened administrative rules. These changes resulted in loss of insurance coverage for thousands of low-income adults nationwide. In this study we assessed the immediate impacts of disrupted and lost Medicaid coverage on adults enrolled in the Oregon Health Plan (OHP) when program changes were implemented. METHODS: Data come from baseline survey results of a prospective cohort study designed to assess the impacts of OHP changes on adult beneficiaries. We used bivariate and multivariate analyses to examine the effects of disrupted and lost insurance coverage on unmet health care needs, utilization, and medical debt occurring in the first 10 months after OHP changes were implemented. RESULTS: After OHP changes were implemented, 31% of enrolled adults reported losing coverage, and another 15% reported disrupted coverage. Controlling for demographic characteristics, income, and health status, those with disrupted coverage were less likely to have a primary care visit (odds ratio [OR] = .66; P <.05) and more likely to report unmet health care needs (OR = 1.85; P <.01) and medical debt (OR = 1.99; P <.01) when compared with those continuously insured. Those who lost coverage were less likely to have a primary care visit (OR = 0.18; P <.01) and more likely to report unmet health care needs (OR = 5.55; P <.01), unmet medication needs (OR = 2.05; P <01), and medical debt (OR = 3.06; P <.01) than those continuously insured. CONCLUSIONS: Medicaid program changes that increase cost sharing and limit enrollment have significant negative impacts on health care access and utilization among Medicaid beneficiaries; these impacts occur rapidly, within the first 10 months after changes.

Adult↗

Patient reports of coverage denial: association with ratings of health plan quality and trust in physician.

OBJECTIVE: To evaluate whether HMO patients' reports of denial of coverage were associated with their ratings of health plan quality and trust in their physician. STUDY DESIGN: Cross-sectional survey. PATIENTS AND METHODS: Within a mixed-model HMO, we surveyed 2000 adult patients who had seen a clinician at least once during the previous year. RESULTS: Of the 2000 patients, 921 (46%) responded. Denial of coverage within the previous 12 months was reported by 64 (7%) patients. Among the denials, 42% were for specialist referral, 32% were for tests or treatments, 18% were for a certain length of hospital stay, and 8% were for a hospital admission. Patients scoring in the lowest quartile on physical functioning were more than twice as likely as other patients to report denial of coverage (12.2% vs 5.1%, P = .001). In multivariable analyses, poor physical functioning remained the only significant independent variable associated with reporting denial of coverage (odds ratio = 3.0; 95% confidence interval, 2.4, 3.6). More than half (53%) of patients reporting denial of coverage said that they had considered leaving the health plan because of concerns about quality of care. These patients also were less likely to express high trust in their primary care physician (64% vs 78%, P < .001). CONCLUSIONS: Patients with poor physical functioning were more likely to report denial of coverage. Perceived denial of coverage was associated with lower ratings of health plan quality and with significantly less trust in patients' own primary care physicians.

Adult↗

Changes in health insurance coverage and health status by race and ethnicity, 1997-2002.

Recent years have seen shifts in health insurance coverage associated with economic fluctuations and changes in health policy. The analysis presented here uses data from the National Survey of America's Families to examine changes in health insurance coverage and respondent-reported health status by race and ethnicity. The data indicate that public coverage increased for black, Hispanic and white children between 1997 and 2002. Uninsurance rates fell among children in low-income black, Hispanic and white families, remained constant among black and white children in higher-income families, and increased among higher-income Hispanic children. The health status of children was stable for blacks, Hispanics and whites except for a decline in health among higher-income Hispanic children. Black and white adults saw increases in public health insurance coverage but not in overall coverage. The uninsurance rate of Hispanic adults increased, despite expanded public coverage of higher-income Hispanic adults. None of these developments altered racial and ethnic disparities in health. Hispanics fared worse than blacks in both health status and insurance coverage, and blacks fared worse than whites. Given the anticipated growth of minority populations in the United States, the nation's health will deteriorate if policymakers allow current disparities to continue.

Adolescent↗

Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials.

BACKGROUND: Current guidelines of empirical antibiotic treatment for inpatients with community-acquired pneumonia recommend antibiotics whose spectrum covers intracellular (atypical) pathogens. No sufficient evidence exists to support the necessity of such coverage, whereas limiting it may reduce toxic effects, resistance, and expense. Our goal was to assess the efficacy of empirical coverage of atypical pathogens in terms of mortality and clinical and bacteriological success. METHODS: Systematic review and meta-analysis of randomized, controlled trials comparing treatment regimens with and without coverage of atypical pathogens. We searched MEDLINE, EMBASE, the Cochrane Library, and references. Relative risks (RRs) with 95% confidence intervals (CIs) were pooled using the fixed-effects model. The primary outcome assessed was all-cause mortality. RESULTS: We included 24 trials encompassing 5015 patients. We found no studies of a drug without atypical coverage that compared it with the same drug supplemented with a drug with atypical coverage; nearly all compared a beta-lactam with a single quinolone or macrolide. There was no difference in mortality between the 2 arms (RR, 1.13 [95% CI, 0.82-1.54]). Regimens with coverage of atypical pathogens showed a trend toward clinical success and a significant advantage to bacteriological eradication. Both disappeared when evaluating methodologically high-quality studies alone. These regimens further showed a significant advantage in clinical success for Legionella pneumophila, whereas no advantage for pneumococcal pneumonia was seen. There was no difference between study arms in the frequency of total adverse events. CONCLUSION: Empirical antibiotic coverage of atypical pathogens in hospitalized patients with community-acquired pneumonia showed no benefit of survival or clinical efficacy in this synthesis of randomized trials.

Anti-Bacterial Agents↗