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PubMed2003

Determinants of health care use by children in rural western North Carolina: results from the Mountain Accessibility Project.

OBJECTIVE: To assess determinants of health care visits among children in a 12-county region of western North Carolina representative of rural areas in the United States. METHODS: Households were randomly selected for surveys of household characteristics, health status, and health care use. Surveys were conducted June 1999 to January 2000 and were stratified for children younger than 5 years and 5 years and older. The number of health care visits in the year before the survey was used as the outcome measure. Weighted mean visits and associations of family demographic and child health variables with the number of visits were determined by ratio and multivariate survey regression methods. RESULTS: Among children who lived in rural Appalachian regions of North Carolina in 1999, 90% had either public or private insurance coverage. The mean number of visits per child was 5.7 (median: 2.6), and in each age group the number of visits in the previous year exceeded the recommended number of well-child visits. There were no apparent geographic access barriers to care in this population, in that increased distances to provider sites did not result in declining numbers of visits. For children younger than 5 years, the primary determinants of health care use during the previous year were age, insurance status, and household income. Infants had more visits than older, preschool children, and those with household incomes >40 000 dollars per year had 76% more visits than those with incomes <20 000 dollars per year. Children with public insurance, exclusively Medicaid in this population, had almost 4 times as many visits as uninsured children. Among the children and adolescents 5 through 17 years of age, health insurance status, household income, pain during the past month, and race were the primary determinants of health care use during the previous year. Those with public health insurance had 6 times more health care visits than uninsured children. Household incomes >40 000 dollars per year were associated with 2.5-fold increased health care visits, and those with household incomes between 20 000 dollars and 40 000 dollars per year had 2-fold increased health care visits, compared with those with household incomes <20 000 dollars per year. White children had almost twice as many visits in the past year as black children in this age group. Pain experienced during the past month, as perceived by the parent, also predicted the number of visits in the older age group. CONCLUSIONS: This rural population seems to have reasonably good access to care overall. The key determinants of health care use among these rural children were similar to those found in urban and other populations in the United States and likely are universal: health insurance coverage, household income, and parent perceptions of their child's pain. As in other populations, programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health. Differential use of health care among white and black children, especially those 5 years and older, merits additional explanation.

Child↗

PubMed1991

Uncompensated hospital care for pregnancy and childbirth cases.

BACKGROUND: The large number of medically indigent patients in the United States is a major concern to policymakers and may be due to recent increases in the number of uninsured people. The purpose of this study was to identify the factors that affect the amount of unpaid hospital charges for services provided to pregnant women. METHODS: Individual and hospital data were collected on a representative set of 235 pregnancy and childbirth patients with unpaid hospital charges from 28 hospitals in the state of Indiana. RESULTS: Most of these patients did not have insurance coverage (63.8%), yet the majority were employed in the public or private sector (72.3%). Over half (55.5%) of the total uncompensated care amount for this group was from the $1000 to 2499 debt category. The median charge for these patients was $1468, of which the typical hospital was able to collect only 25.5%. CONCLUSIONS: The findings support the belief that any national effort to expand the availability of health insurance coverage to women through increased employment will not totally eliminate the uncompensated care problem. The findings also indicate that rural hospitals face the uncompensated care problem mainly because a significant portion of rural patients are without adequate health insurance coverage.

Adolescent↗

PubMed2003

Mandating insurance offers for low-wage workers: an evaluation of labor market effects.

Employing a simultaneous model of part-time status, health insurance offers, and wages, we examine the impacts on employment and health insurance coverage of nondiscrimination rules in the tax code governing employer-sponsored health insurance. Using 1988 and 1993 Employee Benefits Supplements to the Current Population Surveys and variations in health insurance premiums and minimum wages, we find that health insurance coverage among low-wage primary earners is increased by at most 31 percent by the policy, at a cost of an estimated 0.8-5.4-percentage-point decrease in full-time employment for low-wage workers.

Employment↗

PubMed2000

A comparison of the socioeconomic and health status characteristics of uninsured, state Children's health insurance program-eligible children in the united states with those of other groups of insured children: implications for policy.

OBJECTIVES: To describe the sociodemographic and health status characteristics of the national uninsured, State Children's Health Insurance Program (SCHIP)-eligible population, and to compare this population with Medicaid-enrolled children, privately insured children, and privately insured children who have family income in the SCHIP eligibility range. PROCEDURES: Data were analyzed for 50 950 children 0 to 18 years of age included in the 1993 and 1994 National Health Interview Surveys. The survey obtained information on insurance coverage and sociodemographic and health status measures. Bivariate analyses were conducted to identify the relationships between SCHIP eligibility and sociodemographic and health status characteristics. Multivariate analyses were conducted to assess the independent association of the sociodemographic and health status variables with the likelihood of being uninsured, SCHIP-eligible. PRIMARY FINDINGS: Results indicate that SCHIP children exhibit markedly different socioeconomic and health status characteristics than do both Medicaid- enrolled and privately insured children, although these differences are less significant in privately insured children. SCHIP children more often live with college- educated (39.4%) and employed adults (91.2%) than do Medicaid-enrolled children (23.0% and 53.9%, respectively). However, SCHIP children live with college-educated and employed adults less than do all privately insured children (66.7% and 96.9%, respectively) and privately insured/same-income children (57.8% and 97.0%, respectively). Parents of SCHIP-eligible children are also disproportionately self-employed or employed in industries (e.g., retail trade) and occupations in which health insurance coverage is less available or affordable. SCHIP-eligible children are also 2 times more likely to be adolescents and 11/2 times more likely to be in excellent health than Medicaid-eligible children. Compared with privately insured children, SCHIP-eligible children are nearly 3 times more likely to be Hispanic and nearly 2 times more likely to be rated in fair or poor health. CONCLUSIONS: The results demonstrate that uninsured, SCHIP-eligible children are substantially different from children in these groups, particularly compared with Medicaid-enrolled children. These differences need to be taken into account when setting policies and implementing programs intended to increase health insurance coverage and access to health care.

Adolescent↗

PubMedDate not supplied

Selected characteristics of senior citizens prescription drug payment and procurement in 1998 and 2001.

BACKGROUND: People without prescription drug coverage face greater financial burdens and may sometimes be unable to follow the courses of treatment prescribed by their physicians. The U.S. legislature is considering Medicare coverage for prescription drugs and the use of managed care approaches for containing costs associated with senior citizens. prescription drug therapy. OBJECTIVE: The purpose of this study was to describe selected characteristics of senior citizens. prescription drug payment and procurement. METHODS: Data were obtained via mailed survey from national random samples of senior citizens in 1998 and in 2001. Descriptive statistics and regression analyses were used to describe relationships among study variables. RESULTS: Of 2,434 deliverable surveys, 946 (39%) were returned. Of these, 700 (29%) respondents provided usable data for analysis. Results showed that in 2001, compared with 1998, the proportion of senior citizens without any prescription insurance coverage did not change significantly, 29% and 32%, respectively. However, the proportion of respondents with prescription drug coverage who had to share costs of prescriptions through copayments and coinsurance rose significantly, from 69% in 1998 to 89% in 2001. Between 1998 and 2001, the proportion of senior citizens using mail-order pharmacies rose significantly, from 17% to 27%, and the proportion who reported financial hardship also rose, from 19% in 1998 to 31% in 2001. Controlling for year, prescription drug use, and income, logistic regression analysis showed that respondents without any prescription insurance coverage were about 5 times more likely to report financial hardship compared with those having coverage. CONCLUSIONS: The proportion of senior citizens without any prescription drug insurance coverage did not change significantly between 1998 and 2001, but cost sharing in terms of the proportion that had cost-sharing requirements and the amount of the cost sharing through copayments and coinsurance rose significantly. Self-reported financial hardship and the use of mail-order pharmacies among seniors increased between 1998 and 2001.

Aged↗

PubMed1993

Health care reform for Americans with severe mental illnesses: report of the National Advisory Mental Health Council.

This report was produced in response to a request by the Senate Committee on Appropriations that the National Advisory Mental Health Council prepare and submit a report on the cost of insurance coverage of medical treatment for severe mental illness commensurate with the coverage of other illnesses and an assessment of the efficacy of treatment of severe mental disorders. About 5 million Americans (2.8% of the adult population) experience severe mental disorders in a 1-year period. Treating these disorders now costs the nation an estimated $20 billion a year (with an additional $7 billion a year in nursing home costs). These costs represent 4% of total U.S. direct health care costs. When the social costs are also included, severe mental disorders exact an annual financial toll of $74 billion. This total accounts for the dollar costs of shortened lives and lost productivity, as well as the costs incurred in the criminal justice and social service systems. However, it cannot begin to account in human terms for the enormous emotional cost and pain borne by Americans with severe mental illness and by their families. Many myths and misunderstandings contribute to the stigmatization of persons with mental illness and to their often limited access to needed services. For example, millions of Americans and many policy makers are unaware that the efficacy of an extensive array of treatments for specific mental disorders has been systematically tested in controlled clinical trials; these studies demonstrate that mental disorders can now be diagnosed and treated as precisely and effectively as are other disorders in medicine. The existence of effective treatments is only relevant to those who can obtain them. Far too many Americans with severe mental illness and their families find that appropriate treatment is inaccessible because they lack any insurance coverage or the coverage they have for mental illness is inequitable and inadequate. For example, private health insurance coverage for mental disorders is often limited to 30-60 inpatient days per year, compared with 120 days or unlimited days for physical illnesses. Similarly, the Medicare program requires 50% copayment for outpatient care of mental disorders, compared with 20% copayment for other medical outpatient treatment. These inequities in both the public and private sectors can and should be overcome.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

PubMed2004

Impact of private health insurance incentives on obstetric outcomes in NSW hospitals.

The purpose of this study is to analyse the impact of changes in Australian private health insurance coverage as seen in NSW public and private hospital birth profies, and identify trends in obstetric outcomes from 1997-2001. NSW Midwives Data Collection unit record data is analysed for women who gave birth to a live singleton baby of term gestation (> or = 37 weeks) and cephalic presentation in NSW hospitals during 1997- 2001. Use of private hospitals for childbirth has increased in conjunction with increases in private health insurance coverage. Although some obstetric interventions have increased for both public and private hospitals over time, clinical factors do not explain the large differences in birth interventions and outcomes between NSW public and private hospitals. Incentives to increase private health insurance coverage appear to be having a negative impact on childbirth, in terms of higher birth intervention and operative birth rates in NSW private hospitals.

Anesthesia, Obstetrical↗

PubMed1991

Output and inflation components of medical care and other spending changes.

From 1965 to 1990, spending on medical care rose from 5.9 to 12.2 percent of gross national product. This rise was the consequence of greatly expanded government and government subsidized private insurance coverage operating in an environment where payments for insured care by and large covered whatever costs were incurred. As a result, the personal consumption of medical care experienced both output and price average growth rates strikingly above economywide norms. Indeed, the output growth rate in this sector rivaled growth in several goods sectors with greatly expanded supplies. However, whereas goods in the latter sectors have become more accessible through lower relative prices, consumers with insufficient insurance coverage are being crowded out of the market for medical care by higher relative prices.

Health Expenditures↗

PubMed2004

Problems due to medication costs among VA and non-VA patients with chronic illnesses.

OBJECTIVE: To compare rates of cost-related medication underuse and other problems due to medication costs among Department of Veterans Affairs (VA) patients with rates among patients with Medicaid, private health insurance, Medicare, and no insurance coverage. STUDY DESIGN: Nationwide survey. METHODS: A total of 4055 chronically ill patients completed an online questionnaire regarding cost-related adherence problems for medications used to treat 16 chronic illnesses. Respondents also reported whether they cut back on necessities due to medication costs, increased their debt burden to pay for prescriptions, and worried about how they would pay for their medications. RESULTS: Rates of cost-related medication underuse were lower among VA patients (12%) than among patients with Medicaid (25%; P =.0004), Medicare (22%; P =.001), or no insurance (35%; P < .0001). In multivariate analyses, patients with Medicare or no insurance coverage were more likely than VA patients to forego medication at least once per month due to cost (adjusted odds ratios of 3.4 and 3.9; both P < or = .001). Patients with Medicare or no insurance coverage also were more likely than VA patients to forego basic needs to pay medication costs, borrow money to pay for their treatments, and worry frequently about how they would pay for their medication. CONCLUSION: The VA's prescription benefits may prevent problems due to medication costs. Studies assessing the impact of VA prescription coverage on health outcomes and service use will be needed to evaluate the cost-effectiveness of VA drug benefit policies.

Aged↗

PubMed2004

Access to health care among Hispanic/Latino children: United States, 1998-2001.

OBJECTIVE: This report presents national estimates on access to health care for five subgroups of Hispanic/Latino children in the United States: Mexican, Puerto Rican, Cuban, Central or South American, and other Hispanic. For comparison, estimates are also presented for non-Hispanic white children. METHODS: Data for persons of all ages in the U.S. civilian noninstitutionalized population are collected each year in the National Health Interview Survey (NHIS), which is conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Each year, data are collected for approximately 100,000 persons in 40,000 households. In the 1998-2001 surveys combined, 53,510 interviews (14,284 Hispanic/Latino children) were completed by knowledgeable adults for a subsample of children under age 18 years, with an overall response rate of 80.2%. RESULTS: Each year, an estimated 3.0 million (25.7%) Hispanic/Latino children lacked health insurance coverage at the time of interview, 1.6 million (14.1%) had no usual place to go for health care during the past year, and 1.4 million (17.6%) experienced unmet health care needs during the past year due to cost. Of the five Hispanic/Latino subgroups, Mexican children were most likely (30.4%) to lack health insurance coverage, followed by Central or South American children (23.8%) and other Hispanic children (18.6%). The percentage of children having a usual place to go for health care was highest for Cuban children (93.5%) and lowest for Mexican children (83.3%). The percentage of children who experienced unmet medical needs due to cost in the past year was 18.3% for Mexican children, 16.3% for Puerto Rican children, 12.8% for Central or South American children, and 8.3% for Cuban children. Lack of access to health care was most prevalent among Hispanic/Latino children who had poor or near poor poverty status, whose parents had less than a high school diploma, and who were foreign born. CONCLUSION: Access to health care varied among subgroups of Hispanic/Latino children. Understanding subgroup differences may help community-based programs improve access to care among Hispanic/Latino children.

Adolescent↗

PubMed2005

Patient-assistance programs: assessment of and use by safety-net clinics.

PURPOSE: Safety-net clinics' use and assessment of patient-assistance programs (PAPs) were studied. METHODS: A multistate telephone survey was conducted on the basis of issues identified during 10 case-study interviews of safety-net clinics serving primarily uninsured and publicly insured patients. Interviewed were pharmacists and other staff taking primary responsibility for helping patients apply to PAPs. RESULTS: Of 339 survey candidates, 215 provided complete interviews (63% response rate). Ninety-three percent of the completed interviews were with clinics in California, Texas, and Florida. Forty percent of the clinics reported that at least 75% of their patients lacked drug insurance coverage. There was a significant positive relationship between a clinic's likelihood of using PAPs and the percentage of its patients lacking drug coverage. PAPs consumed 12 hours of pharmacist time per month and 99 hours of other staff time per month. Clinics most frequently cited program requirements changing without notice and unrealistic income-documentation rules as potential barriers to PAP use and indicated that consistent eligibility criteria and standardized application procedures were needed. CONCLUSION: A survey of safety-net clinics indicated that PAPs help fill a major gap in health insurance coverage but that consistent eligibility criteria and application procedures are needed.

Ambulatory Care↗

PubMed1989

Private long-term care insurance: after coverage restrictions is there anything left?

Private long-term care insurance has been suggested as a solution to the crushing burden of out-of-pocket expenditures for nursing home and home health care. This paper examines the effects of common policy restrictions among currently marketed policies, more than a million of which have been sold. Using a conditional probabilities model and data from the 1985 National Nursing Home Survey (NNHS), we estimate likelihood of policy compliance for 31 combinations of policy restrictions. Compliance estimates range from 8.5% to 91.9%. Results indicate that prior hospitalization and prior skilled care clauses represent significant stumbling blocks for policyholders seeking benefit payments.

Data Collection↗

PubMed2002

Stability and change in health insurance among older Mexican Americans: longitudinal evidence from the Hispanic established populations for epidemiologic study of the elderly.

OBJECTIVES: This study examined the association between health insurance coverage, medical care use, limitations in activities of daily living, and mortality among older Mexican-origin individuals. METHODS: We analyzed longitudinal data from the Hispanic Established Populations for Epidemiologic Study of the Elderly (H-EPESE). RESULTS: The uninsured tend to be younger, female, poor, and foreign born. They report fewer health care visits, are less likely to have a usual source of care, and more often receive care in Mexico. Conversely, those with private health insurance are economically better off and use more health care services. Over time, the data reveal substantial changes in type of insurance coverage. CONCLUSIONS: The data reveal serious vulnerabilities among older Mexican Americans that result from a lack of private Medigap supplemental coverage.

Activities of Daily Living↗

PubMed2001

A health insurance tax credit for uninsured workers.

This paper describes a new system of tax credits to help low-income workers pay for health insurance. The system would be designed to subsidize health insurance coverage for workers who are currently uninsured, or who pay high premiums for nongroup insurance. Anyone age 19 or older who is not covered by Medicaid, Medicare, or employer-sponsored health insurance would be eligible for a health insurance tax credit (HITC), administered through the Internal Revenue Service. The base amount of the proposed credit would be $2,000 per year for each covered individual, but this amount would be adjusted for the individual's age and sex, according to the effect of age and sex on the cost of insurance coverage. The base amount of the credit would be reduced by $150 for every $1,000 by which a person's income exceeded 200% of the federal poverty level, thus limiting HITC eligibility to lower-income workers. To encourage participation in the credit program, most of the credit would be available through an advance payment system, with final reconciliation after year's end.

Adult↗

PubMed2005

Association between underinsurance and access to care among children with special health care needs in the United States.

OBJECTIVE: To examine the impact of underinsurance on access to care among children with special health care needs (CSHCN) in the United States. METHODS: Interviews were conducted by telephone with the families of 38866 CSHCN who were younger than 18 years using the 2001 National Survey of Children With Special Health Care Needs. The prevalence of underinsurance and its relationship to access to care and family financial problems was examined in this cross-sectional analysis. CSHCN were classified as underinsured when coverage was deemed inadequate to meet the child's needs. RESULTS: An estimated 12.8% of US children experienced a special health care need in 2001. Although 95% of CSHCN had some type of insurance coverage at the time of the interview, 32% were classified as underinsured. Underinsured CSHCN were disproportionately represented in low-income families and were significantly more likely than fully insured children to have unmet health needs, and their families were more likely to report difficulty in obtaining specialty referrals, experience financial problems, and report that the child's condition caused family members to reduce or stop work. Underinsured CSHCN seemed to be somewhat better off than CSHCN with no insurance coverage on these measures. CONCLUSIONS: Underinsured CSHCN represent an important and largely hidden underserved population.

Child↗

PubMed1988

Reimbursement issues in clinical oncology.

In this multidisciplinary review, health-care specialists present practical solutions to the dilemma of rising costs v the need for adequate medical care for all Americans. The United States is the only advanced industrial society that makes ability to pay a critical determinant in health care. As the costs of patient care and insurance coverage escalate, the public demands greater value in insurance coverage with enhanced access to adequate care, clinical trials, and experimental therapies. Greater cooperation is needed between third-party payers, business, and government to create a system that provides optimal care today while supporting innovation and emerging technology for the future.

Antineoplastic Agents↗

PubMed2001

Antihypertensive medication use in Hispanic adults: a comparison with black adults and white adults.

BACKGROUND: Variations in awareness, treatment, and control of hypertension among different racial/ethnic groups have been widely reported. It is unclear whether these differences are explained fully by differences in socioeconomic status, insurance coverage, health status, and health behaviors, or whether these differences indicate that racial/ethnic subgroups have unique barriers to hypertension control. OBJECTIVES: Determine whether there are significant differences between racial/ethnic groups in medication use for hypertension after adjusting for potentially confounding variables. RESEARCH DESIGN: Cross-sectional analysis of the 1992 Health and Retirement Study. SUBJECTS: 2450 non-Hispanic white, 939 non-Hispanic black, and 345 Hispanic participants, ages 51 to 61, reporting a history of hypertension. MEASURES: Self-reported current antihypertensive medication use. We used logistic regression to adjust for demographics, socioeconomic status, health status, insurance, and health risk behaviors. RESULTS: 63.6% of white adults, 72.6% of black adults, and 52.5% of Hispanic adults reported current medication use to control hypertension (P <0.001 across all three groups). In stratified analysis, the lower rate of use for Hispanic adults was consistent regardless of gender, insurance coverage, or health status. After controlling for all variables, the adjusted prevalence for Hispanic adults was 50.8% and 73.3% for black adults. CONCLUSIONS: The differences in antihypertensive medication use between white adults, black adults, and Hispanic adults, particularly the markedly lower rates among Hispanic adults, are not explained by differences in demographics, socioeconomic status, health insurance coverage, health status, or health risk behaviors. Alternative explanations for these results and areas for future research and intervention are explored.

Black or African American↗

PubMed2004

Use of cervical cancer screening among insured women: the extent of missed opportunities.

The objective of the study is to identify opportunities to improve cervical cancer screening among privately insured women. From MedStat's Marketscan database, we identified 735,181 women aged 21-64 years who remained in the same insurance plan during the entire period of 2000-2002. We obtained the percentages of women who had a Papanicolaou (Pap)-test reimbursement claim and any health-related claim during the 3-year period. For women without a Pap-test claim, we obtained information about the frequency of insurance claims, type of health-care provider, and type of insurance plan in which the women were enrolled. The multivariate logistic regression model was used to identify factors independently associated with not having a Pap test. Of the total sample, in the 3-year period, 96% had at least one health insurance reimbursement claim and 69% had at least one claim for a Pap test. Approximately, 87% of the women who had no Pap-test claim had a health claim; 44% of such claims were from primary care providers. In the multiple logistic regression model, factors that were independently associated with having no Pap test were old age, being dependents of employees, and enrollment in comprehensive insurance plans. Efforts to increase the use of cervical cancer screening service should consider additional risk factors besides lack of insurance coverage. Concerted efforts by insurance and health-care providers are needed to improve adherence to the recommended cervical cancer screening guidelines, both by consumers and service providers.

Adult↗