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PubMed1993

Fixing the individual health insurance market.

The individual health insurance market is in crisis. Among the possible options for reform, a managed competition approach offers the broadest, most comprehensive solution.

Competitive Medical Plans↗
PubMedDate not supplied

Clients without health insurance at publicly funded HIV counseling and testing sites: implications for early intervention.

The characteristics of clients reporting no health insurance were compared with those reporting any health insurance at publicly funded human immunodeficiency virus (HIV) counseling and testing sites in the United States during 1992. Thirty of 65 funded health departments collect data on self-reported health insurance status. Data were dichotomized into two groups, clients reporting any health insurance versus those reporting none, and multivariate logistic models were developed to explore independent associations. Of the 885,046 clients studied, 440,416 reported that they lacked health insurance. Clients without health insurance were more likely to be male, members of racial or ethnic minorities, adolescent, and HIV seropositive. Prisoners (odds ratio = 0.26), clients of Hispanic ethnicity (odds ratio = 0.52), and clients receiving testing during field visits (odds ratio = 0.53) in drug treatment centers (odds ratio = 0.55) and in tuberculosis clinics (odds ratio = 0.55) were less likely to have health insurance. Injecting drug users, whether heterosexual (odds ratio = 0.65) or homosexual (odds ratio = 0.67), were less likely to have health insurance compared with other behavioral risk groups. Large numbers of clients receiving publicly funded HIV counseling and testing lack health insurance. Lack of health insurance may interfere with subsequent receipt of needed primary care services among high-risk clients, especially HIV seropositive clients in need of early intervention services.

Adolescent↗
PubMed2004

Health insurance--a challenge in India.

In India, indemnity health insurance started about 3 decades ago. Mediclaim was the most popular product. Indian insurers and multinational companies have not been enthusiastic about starting health insurance in spite of the availability of a good market because health insurers have historically incurred losses. Losses have been caused by poor administration. Because it is a small portion of their total businesses, insurers have never tried sincerely to improve deficiencies or taken special interest. Hospital management and medical specialists have the spirit of entrepreneurship and are prepared to learn quickly and follow managed care principles, though they are not currently practiced in India. Actuarial data from the health insurance industry is sparse, but data from alternative sources will be helpful for starting managed healthcare. In my opinion, if properly administered, a "limited" managed care product with appropriate precautions and premium levels will be successful and profitable and will compete with present indemnity products in India.

Actuarial Analysis↗
PubMedDate not supplied

Health insurance and the homeless.

There is very little known about health care utilization among the homeless or about the role of health insurance on utilization patterns. Many health care reform proposals advocate expanding health insurance coverage for various segments of society, including the homeless. Although homeless people who lack health insurance face strong financial barriers to health services, providing them with health insurance may not appreciably increase their demand for health care if they also face important non-financial barriers. We investigate the relationship between insurance and utilization for this group based on estimates from an empirical model of medical care use and insurance coverage. Using our estimates, we simulate potential effects of policy changes on various types of utilization, including use of mental health services and treatment for alcohol or other drug abuse.

Adult↗
PubMed2005

Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program.

BACKGROUND: Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. OBJECTIVES: The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. METHODS: Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. RESULTS: Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. CONCLUSIONS: Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

Adolescent↗
PubMed2000

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative.

BACKGROUND: Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. METHODS: Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. RESULTS: Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. CONCLUSIONS: In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.

Age Factors↗
PubMed2003

Support for national health insurance among U.S. physicians: a national survey.

BACKGROUND: Nearly 40 million persons in the United States were without health insurance for all of 2000. National health insurance would remedy this situation, and many believe the success of reform efforts in this direction may depend on physician support. OBJECTIVE: To determine the general attitudes of U.S. physicians toward the financing of national health care. DESIGN: Cross-sectional study. SETTING: National mailed survey. PARTICIPANTS: 3188 randomly sampled physicians from the American Medical Association Physician Masterfile. MEASUREMENTS: Physicians were asked whether they support or oppose 1) governmental legislation to establish national health insurance and 2) a national health insurance plan in which all health care is paid for by the federal government. Weighted multivariate logistic regression analyses were performed to identify factors that independently predicted support for each of these strategies. RESULTS: Sixty percent of eligible participants returned a survey. Forty-nine percent of physicians supported governmental legislation to establish national health insurance, and 40% opposed it. Only 26% of all physicians supported a national health insurance plan in which all health care is paid for by the federal government. In analyses adjusting for differences in personal and practice characteristics, physicians in a primary care specialty, physicians reporting that at least 20% of their patients had Medicaid, and physicians practicing in a nonprivate setting or in an inner-city location were statistically significantly more likely to support governmental legislation to establish national health insurance. CONCLUSIONS: A plurality of U.S. physicians supports governmental legislation to establish national health insurance. This support may be relevant to the success of future efforts to reform national health care.

Attitude of Health Personnel↗
PubMed2000

Reforming health insurance in Argentina and Chile.

The paper examines the recent reforms of health insurance in Chile and Argentina. These partially replace social health insurance with individual insurance administered through the private sector. In Chile, reforms in the early 1980s allowed private health insurance funds to compete for affiliates with the social health insurance system. In Argentina, reforms in the 1990s aim to open up the union-administered social insurance system to competition both internally and from private insurers. The paper outlines the specific articulation of social and individual health insurance produced by these reforms, and discusses the implications for health insurance coverage, inequalities in access to healthcare, and health expenditures.

Adolescent↗
PubMed1989

Case-mix adjusted analyses of service utilization for a Medicaid health insuring organization in Philadelphia.

Health Insuring Organizations (HIOs) are capitated plans that serve all of the Medicaid beneficiaries in a defined catchment area. While this approach to capitation eliminates the incentive to enroll only the healthiest beneficiaries in the area, it does not alleviate concerns that the HIO will respond to the incentives for efficiency created by capitation payment by underproviding services. The authors studied change in service utilization patterns produced by the HIO by using a multivariate strategy to identify case-mix groups at the population level to adjust analyses of hospital and nursing home utilization for case mix. This approach was applied to service utilization data for Medicaid beneficiaries in Philadelphia who received medical services from an HIO and for two control groups. In addition to identifying changes in service use, they evaluated the performance of the HIOs on three dimensions--access to care, quality of care, and the efficiency with which the care was provided. While limitations on the information available in the billing files did not allow definitive statements to be made regarding these issues, case-mix adjusted patterns of service use (and mortality) across sets of service may enable Medicaid programs to identify areas where problems in one of these three critical areas exist. This would allow the program to target its limited utilization and quality review resources toward the areas, types of people, and/or providers where problems in one or more of these areas are more likely.

Actuarial Analysis↗
PubMed2004

[Demands on and benefit from insurance-orientated hospital management - findings from qualitative interviews with executive members of statutory health insurance].

PURPOSE: Starting from the fact that statutory health insurance bodies are increasingly important hospital stakeholders, the article focuses on the question of demands on and benefit from an insurance-orientated hospital management. METHOD: A methodological approach is chosen which takes the views of the stakeholder health insurance as a starting point: Semi-structured interviews were conducted with 14 executives of different statutory health insurance. Data analysis was based on the "zusammenfassende Inhaltsanalyse" (literal translation: summarizing content analysis), developed by Mayring. RESULTS: From the participants' points of view the highly regulated relationship between hospitals and insurances offers opportunities for active development. The analysis of expectance distinguishes between five areas of demand: "Hospital services", "service development", "case management", "management of conflicts/reviews" and "budget negotiations". Within these areas dimensions of demand are differentiated. Most participants feel that an insurance-oriented hospital management is beneficial to the hospital. CONCLUSION: A number of specific demands is identified on which management activities can be based. Hospitals need to consider carefully the benefit of insurance-orientation and suitable measures in the light of hospital-specific aims and strategies.

Budgets↗
PubMed1993

The politics of reform: public health insurance in Canada.

The centerpiece of Canadian health policy is a system of public health insurance covering the cost of hospital and medical services for all Canadians. The author analyzes the historical development of this policy and critically assesses its structure and dynamics. He argues that health insurance was won by Canadian workers through protracted industrial and political struggle. At the same time, health insurance was accommodated to the existing structure of power and privilege within the health care delivery system, which precluded a significant shift in the distribution of health care consumption and perpetuated the "irrationality" of a system that treats health as a problem located in the sphere of personal consumption.

Canada↗
PubMed2006

What should (public) health insurance cover?

In any system of health insurance, a decision must be made about what treatments the insurance should cover. One way to make this decision is to rank treatments by their ratios of health benefits to treatment costs. If treatments that are not offered by the health insurance can be purchased out of pocket, the socially optimal ranking of treatments to be included in the health insurance is different from this standard cost-effectiveness rule. It is no longer necessarily true that treatments should be ranked higher the lower are treatment costs (for given health benefits). Moreover, the larger are the costs per treatment for a given benefit-cost ratio, the higher priority should the treatment be given. If the health budget in a public health system does not exceed the socially optimal size, treatments with sufficiently low costs should not be performed by the public health system if treatment may be purchased privately out of pocket.

Health Care Costs↗
PubMed2003

[The state and health insurance].

The relationship between the State and the health insurance passes through an institutional and financial crisis, leading the government to decide a new governance of the health care system and of the health insurance. The onset of the institutional crisis is the consequence of the confusion of the roles played by the State and the social partners. The social democracy installed by the French plan in 1945 and the autonomy of management of the health insurance established by the 1967 ordinances have failed. The administration parity (union and MEDEF) flew into pieces. The State had to step in by failing. The light is put on the financial crisis by the evolution of ONDAM (National Objective of the Health Insurance Expenses) which appears in the yearly law financing Social Security. The drift of the real expenses as compared to the passed ONDAM bill is constant and worsening. The question of reform includes the link between social democracy to be restored (social partners) and political democracy (Parliament and Government) to establish a contractual democracy. The Government made the announcement of an ONDAM sincere and medically oriented, based on tools agreed upon by all parties. The region could become a regulating step involving a regional health council. An accounting magistrate would be needed to consider not only the legal aspect but to include economic fallouts of health insurance. The role and the missions of the Social Security Accounting Committee should be reinforced.

Financial Management↗