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PubMedDate not supplied

Patterns of insurance coverage within families with children.

This paper examines patterns of health insurance within families with children, using the 1996 Medical Expenditure Panel Survey (MEPS). Four and a half million families (14 percent) had insurance for some, but not all, family members. These partially insured families generally obtained coverage because of one of three situations: (1) A parent earned relatively higher wages and received the concomitant benefits of such jobs but could not afford dependent coverage; (2) the family had young children who were covered by Medicaid through more generous eligibility thresholds for children under age six, while other family members were ineligible; or (3) the family had a member who was eligible for public coverage because of a disability. Each of these situations offers the platform from which incremental policies might efficiently expand coverage to families.

Adolescent↗
PubMedDate not supplied

Do physicians not offer useful services because of coverage restrictions?

Ethically, physicians should discuss all medically appropriate services with patients, but coverage restrictions can make these discussions difficult. In a national survey of physicians, we asked how often physicians elected not to offer their patients useful services because of health plan coverage rules. During the course of a year, 31 percent reported having sometimes not offered their patients useful services because of perceived coverage restrictions. Among these, 35 percent reported doing so more often in the most recent year than they did five years ago. It can be frustrating for doctors to discuss uncovered services with their patients, but open communication is necessary for shared decision making and to improve coverage decisions.

American Medical Association↗
PubMedDate not supplied

Covering kids: variation in health insurance coverage trends by state, 1996-2002.

We estimated state-specific changes in health insurance coverage rates for children between 1996-1998 and 2001-2002. We found considerable variation in the changing distribution of health insurance coverage for children across states, with significant increases in public program coverage in twenty-nine states and significant decreases in uninsured children in twenty-seven. Children in families with incomes below 200 percent of the federal poverty level were the most likely to enroll in public programs. We provide an overview of state outreach and administrative simplification efforts and raise concerns about the persistent variation in children's health insurance coverage across states.

Adolescent↗
PubMedDate not supplied

Expanding individual health insurance coverage: are high-risk pools the answer?

Thirty states operate high-risk pools intended to offer coverage to persons denied coverage in the individual health insurance market. But in most states the high-risk pool mirrors the individual market's problems: Coverage is expensive, the waiting period for coverage of preexisting conditions is long, and benefits may be limited. A few states with high-risk pools have addressed these problems by adequately funding high enrollment and comprehensive benefits; some also require the market to accept more risk. But most discourage enrollment in the high-risk pool in myriad ways and fall to ensure access to the individual market for persons with health problems.

Health Policy↗
PubMedDate not supplied

The nongroup market as one element of a broader coverage-expansion strategy.

Effective health insurance provides financial protection and access to services that maintain and improve health. Such coverage is difficult to obtain in the nongroup market, however, because of a lack of sponsorship, the nature of coverage available, adverse selection, and high administrative costs. However, certain interventions could make this market an effective avenue for expanding coverage to moderate- to high-income persons who lack access to employer-based coverage. In "less regulated" markets, we suggest broader, deeper funding of high-risk pools and standardization of benefits, preexisting condition exclusions, and waiting periods. In "more regulated" markets, a broadly funded reinsurance mechanism could moderate premiums.

Fees and Charges↗
PubMedDate not supplied

Cost-effectiveness and evidence evaluation as criteria for coverage policy.

Private health plans and government health insurance programs in the United States base their coverage decisions on evidence criteria, rather than explicit cost-effectiveness criteria. As health spending continues to grow rapidly, however, approaches to coverage policy that ignore costs fail to meet the needs of consumers, employers, health plans, and federal and state governments. I describe the role of evidence-based criteria in formal coverage decision making and contrast the ways that these criteria differ from cost-effectiveness criteria. Finally, I discuss options for incorporating considerations of cost-effectiveness into coverage policy and other aspects of benefit design.

Cost-Benefit Analysis↗
PubMedDate not supplied

Prescription drug coverage and seniors: findings from a 2003 national survey.

Beginning in 2006 the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) will offer pharmacy benefits to forty-two million Medicare beneficiaries nationwide. In a 2003 national survey of Medicare beneficiaries age sixty-five and older, more than one-quarter reported no prescription coverage, and nearly half of low-income seniors in some states lacked coverage. Wide coverage differences among states highlight implementation challenges and the need for tailored enrollment strategies. Evidence of Medicaid's highly effective coverage delineates the importance of assuring this group's continued protection under Part D plans. Reports of complex drug regimens, multiple prescribing physicians and pharmacies, nonadherence, and reimportation demonstrate the challenges of integrating seniors' prescription care. We discuss MMA's potential to improve quality and the need to monitor performance.

Aged↗
PubMed2004

Lack of insurance coverage for testing supplies is associated with poorer glycemic control in patients with type 2 diabetes.

BACKGROUND: Public insurance for testing supplies for self-monitoring of blood glucose is highly variable across Canada. We sought to determine if insured patients were more likely than uninsured patients to use self-monitoring and whether they had better glycemic control. METHODS: We used baseline survey and laboratory data from patients enrolled in a randomized controlled trial examining the effect of paying for testing supplies on glycemic control. We recruited patients through community pharmacies in Alberta and Saskatchewan from Nov. 2001 to June 2003. To avoid concerns regarding differences in provincial coverage of self-monitoring and medications, we report the analysis of Alberta patients only. RESULTS: Among our sample of 405 patients, 41% had private or public insurance coverage for self-monitoring testing supplies. Patients with insurance had significantly lower hemoglobin A(1c) concentrations than those without insurance coverage (7.1% v. 7.4%, p = 0.03). Patients with insurance were younger, had a higher income, were less likely to have a high school education and were less likely to be married or living with a partner. In multivariate analyses that controlled for these and other potential confounders, lack of insurance coverage for self-monitoring testing supplies was still significantly associated with higher hemoglobin A(1c) concentrations (adjusted difference 0.5%, p = 0.006). INTERPRETATION: Patients without insurance for self-monitoring test strips had poorer glycemic control.

Aged↗
PubMed2003

Intermittent lack of health insurance coverage and use of preventive services.

OBJECTIVES: This study examined the association between intermittent lack of health insurance coverage and use of preventive health services. METHODS: Analyses focused on longitudinal data on insurance status and preventive service use among a national sample of US adults who participated in the Health and Retirement Study. RESULTS: Findings showed that, among individuals who obtain insurance coverage after histories of intermittent coverage, relatively long periods may be necessary to reestablish clinically appropriate care patterns. Increasing periods of noncoverage led to successively lower rates of use of most preventive services. CONCLUSIONS: Intermittent lack of insurance coverage-even across a relatively long period-results in less use of preventive services. Studies that examine only current insurance status may underestimate the population at risk from being uninsured.

Episode of Care↗
PubMed2004

Insurance coverage of smoking cessation treatment for state employees.

Public health experts recommend that health insurance include coverage for smoking cessation treatment as an evidence-based strategy to reduce smoking. As employers, states can implement this policy for more than 5 million individuals nationwide. This study identified the extent to which states require smoking cessation treatment insurance coverage for their employees; of 45 states, 29 required coverage for at least 1 US Public Health Service (PHS)-recommended treatment, and only 17 of 45 provided coverage that was fully consistent with PHS recommendations.

Counseling↗
PubMedDate not supplied

Employer coverage of clinical preventive services in the United States.

PURPOSE: To characterize employers' coverage of clinical preventive services. DESIGN: Mercer Human Resource Consulting Inc. included questions on clinical preventive services as part of its National Survey of Employer-Sponsored Health Plans, 2001. SETTING: A national sample of employers of a large, medium, and small number of employees, including governments. SUBJECTS: Respondents self-identified as most knowledgeable about the organization's health benefits. MEASURES: Weighted analyses of responses to eight survey questions on health promotion. RESULTS: The survey was completed by 2180 employers, and the response rate was 21%. More than 90% of employers included increased productivity and decreased health care costs among their most important reasons for coverage of clinical preventive services. Within health insurance, coverage of physical examinations, immunizations, and screenings generally exceeded 50%, but coverage of lifestyle modification services was less than 20%. Only 20% of employers covered tobacco cessation services, and only 4% of employers provided an "optimal" benefit. We compared employers' offerings with a published ranking, by impact and value, of clinical preventive services. We found the biggest discrepancy in tobacco cessation services and alcohol problem prevention, which ranked high in terms of impact and value but are offered by only 20% and 18% of employers, respectively. CONCLUSIONS: Employers seek financial return from their offerings of clinical preventive services to employees, but they are least likely to offer the services most likely to provide this return.

Health Benefit Plans, Employee↗
PubMed2004

The financial implications of coverage of smoking cessation treatment by managed care organizations.

This paper presents results from a simulation of the financial impact and cost effectiveness of smoking cessation in a hypothetical managed care organization (MCO), using data from three large managed care organizations and from existing literature. With base-case assumptions and a market cost of capital, at five years, coverage of cessation services costs an MCO dollars .61 per member per month (PMPM). In a steady-state situation, net cost is dollars .41 PMPM. Both values include altered medical expenditures and MCO revenue patterns attributable to coverage-induced cessation. Quitters gain an average of 7.1 years of life, with a direct coverage cost of dollars 3,417 for each life-year saved. Coverage of cost-effective programs by MCOs should be strongly encouraged.

Cohort Studies↗
PubMed2006

Health insurance coverage for vulnerable populations: contrasting Asian Americans and Latinos in the United States.

This paper examines the role that population vulnerabilities play in insurance coverage for a representative sample of Latinos and Asians in the United States. Using data from the National Latino and Asian American Study (NLAAS), these analyses compare coverage differences among and within ethnic subgroups, across states and regions, among types of occupations, and among those with or without English language proficiency. Extensive differences exist in coverage between Latinos and Asians, with Latinos more likely to be uninsured. Potential explanations include the type of occupations available to Latinos and Asians, reforms in immigration laws, length of time in the United States, and regional differences in safety-net coverage. Policy implications are discussed.

Adolescent↗
PubMed1998

Technology assessment, coverage decisions, and conflict: the role of guidelines.

As pressure grows for health plans to be accountable for increasing quality of care within a cost-control environment, coverage of new technologies becomes a particularly challenging issue. For a number of reasons, health plans have adopted evidence-based methods for guiding technology decisions. The implementation of these methods has not been free of controversy, and conflicts have arisen between plans and proponents of technologies who often use the political and legal arena in an attempt to secure coverage. Unless these conflicts are resolved, the healthcare system may have difficulty meeting cost and quality objectives. Technology assessment and coverage process guidelines and flexible coverage approaches may be possible ways of resolving these conflicts.

Conflict of Interest↗
PubMed1998

Role of technology assessment in health benefits coverage for medical devices.

With the profusion of new medical technology, managed care organizations are faced with the challenge of determining which medical devices and services warrant health benefits coverage. To aid in this decision-making process, managed care companies turn to technology assessment, a process that differs from the Food and Drug Administration's review of medical devices. Health plans typically use a structured approach to implementing coverage requirements in employer group benefits contracts and use technology assessment to evaluate the scientific evidence of effectiveness to support coverage decisions. Also important is the societal context for decisions regarding coverage for new technologies and the options being considered by policy makers for accountability in technology assessment by private insurers and health plans.

Cost-Benefit Analysis↗
PubMed1994

The print media and aging policy: how differential coverage of Medicare Catastrophic led congress astray.

This article examines the role of the print media in covering complex policy issues. Two models of journalism are considered. "Pack journalism" predicts that print media coverage will be highly consistent in content due to the reliance by those in the media on the same sources of information. In this article, another model--"Beltway journalism"--is proposed. It implies that coverage by the print media indigenous to the Washington, D.C. area (inside the Beltway) will diverge from that of other print media, presenting a potentially distorted view of the world to policymakers in Washington. Using the Washington Post and the Los Angeles Times as possible indicators of the two models, aging policy is addressed through a case study of newspaper coverage during passage and repeal of the Medicare Catastrophic Coverage Act of 1988. Findings suggest that Congress was unduly influenced by the way that Medicare Catastrophic was framed in the Washington Post, lending credence to the Beltway journalism model. By paying insufficient attention to the way Medicare Catastrophic was being framed by sources of print outside the Beltway area, lawmakers allowed themselves to assume a grassroots-level understanding of the issue and support for the bill, both of which turned out to be illusory.

Aged↗
PubMed1999

Prescription drug coverage and spending for Medicare beneficiaries.

Outpatient prescription drug coverage is not a Medicare covered benefit. Debate continues in Congress and elsewhere on modernizing the Medicare benefit package, including proposals that would help the Nation's seniors pay for prescription drugs. Very little is known about which persons within the Medicare population have drug coverage from other sources. Using 1995 data from the Medicare Current Beneficiary Survey (MCBS), the authors present information on who has coverage by various sociodemographic categories. The data indicate higher-than-average levels of coverage for minority persons, beneficiaries eligible for Medicare because of disability, and those with higher incomes.

Adolescent↗
PubMed1999

A model for improving coverage policy decisions.

Reasoned and defensible coverage decisions are essential for a fairer and more efficient healthcare system. Because healthcare resources are finite, coverage decisions should be informed by economic evaluations and made from a perspective that attends to the interests of both individuals and the population enrolled in a plan as a whole. Coverage decisions for all healthcare interventions should follow a 2-step procedure that consists of (1) the relatively impartial and objective assessment of an intervention's eligibility for coverage and (2) the distinctively value-laden determination (for which the enrolled population's values and preferences should take priority) to cover, conditionally cover, or not cover an intervention.

Decision Making↗