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PubMed2006

Crowd-in: the effect of private health insurance markets on the demand for Medicaid.

OBJECTIVE: To investigate the effects of local labor market conditions and the availability of employer-sponsored health insurance on exits from the Medicaid program. DATA SOURCE: Data for this project come from a unique administrative database containing a 2 percent sample of all cases on California's Medicaid program in 1987 and a 2 percent sample of all new cases starting each year between 1987 and 1995. STUDY DESIGN: The results are estimated using a discrete duration model where the monthly exit probability is a function of demographic characteristics, local labor market variables, the probability of having employer-sponsored insurance, and fixed year and county effects. PRINCIPAL FINDINGS: Improvements in labor market opportunities (i.e., employment growth, wage growth, and increases in the availability of employer-sponsored health insurance) promote exits off the Medicaid program. A 2.5 percentage point increase in the availability of employer-sponsored insurance leads to a 6 percent increase in the probability that a completed spell lasts no more than 2 years. It would take a 2 percentage point decrease in unemployment rates or a 10 percent increase in average quarterly earnings to yield an equivalent increase in the likelihood of exiting Medicaid within 2 years. These effects are robust to the inclusion of county-level fixed effects and time effects. CONCLUSIONS: Medicaid expenditures and caseloads are sensitive to local economic fluctuations and secular trends in the availability of health insurance. Continued decreases in employer-based health insurance coverage will greatly increase the demand for public insurance coverage and the financial pressures on state governments.

Adolescent↗
PubMed1996

Redefining private insurance in a changing market structure.

This discussion on likely changes and challenges for the health insurance industry over the coming decade assumes that significant national reform of health care financing for the privately insured population will not occur--or, if it does, that it will mirror the insurance market reforms that many states already have undertaken. First, the changes in private insurance coverage during the past several years are considered, with particular attention to the erosion of employer-based coverage and to the rising influence of public insurance programs--especially Medicaid--on the private insurance market. Next is a description of the changing web of state laws and regulations governing private health insurance. At this writing, virtually every state has enacted or is considering reforms of the small group market to limit what many perceive as unfair or destructive insurer practices and to set new ground rules for competition among insurance arrangements. The changing nature of private insurance contracts in the United States is considered next. Evolving from conventional fee-for-service contracts, private insurance is increasingly a complex mixture of capitation, partial capitation, and reinsurance of capitated arrangements. Finally, this chapter discusses three issues of increasing importance in shaping the marketplace for private insurers: (1) the federal preemption of states' regulatory authority over self-insured employer plans; (2) emerging state regulation to restructure competition in the health insurance and health care markets; and (3) the growing interest of both federal and state governments in medical savings accounts to finance health insurance and health care spending.

Capitation Fee↗
PubMed2006

The economic burden of prescription drug use among elderly patients in Ponce, Puerto Rico.

OBJECTIVE: To examine the economic impact of prescription drug use on the personal income of elderly individuals in Ponce, Puerto Rico. METHODS: One-hundred elderly individuals who attend five care centers were interviewed using a four-page structured questionnaire. The interview collected information about the source and amount of income of participants, the type of insurance coverage for prescription drugs, the amount of expenditures for prescription drugs that are paid out-of-pocket and the barriers they face to use or obtain prescription drugs. RESULTS: Participants were mostly female (69%) and the average age was 77 years. The average monthly income reported was 476 dollars, 79% of which was derived from Social Security. The average monthly expenditure was 364.00 dollars of which 117.00 dollars (32%) was spent on health related expenditures: 70.00 dollars (19%) on prescription drugs, 31.00 dollars (8%) on health insurance premiums, 10.00 dollars (3%) on medical expenditures not related to prescription drugs, and 6.00 dollars (2%) on over-the-counter drugs. The great majority reported having health insurance but one-third pay out-of-pocket for their prescription drugs. Nearly two-thirds expressed they have experienced problems to obtain or use medications in the past six months. Thirty-eight percent reported that the problem was that the cost of medications was too high. CONCLUSION: In spite of insurance coverage, the cost of prescription drugs places a substantial economic burden on elderly individuals. On average, prescription drug expenditures comprise nearly 20% of the personal expenditures of respondents, second only to groceries. This accounts for 15% of their personal income. The economic burden of prescription drugs on the elderly may affect access to needed drugs and may adversely impact health outcomes.

Age Factors↗
PubMed1997

Interim rules for mental health parity--IRS, DoL, HCFA. Interim rules with request for comments.

This document contains interim rules governing parity between medical/surgical benefits and mental health benefits in group health plans and health insurance coverage offered by issuers in connection with a group health plan. The rules contained in this document implement changes made to certain provisions of the Internal Revenue Code of 1986 (Code), the Employee Retirement Income Security Act of 1974 (ERISA or Act), and the Public Health Service Act (PHS Act) enacted as part of the Mental Health Parity Act of 1996 (MHPA) and the Taxpayer Relief Act of 1997. Interested persons are invited to submit comments on the interim rules for consideration by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services (Departments) in developing final rules. The rules contained in this document are being adopted on an interim basis to ensure that sponsors and administrators of group health plans, participants and beneficiaries, States, and issuers of group health insurance coverage have timely guidance concerning compliance with the requirements of MHPA.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1999

Legalized physician-assisted suicide in Oregon--the first year's experience.

BACKGROUND AND METHODS: On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. RESULTS: Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). CONCLUSIONS: During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education or health insurance coverage.

Activities of Daily Living↗
PubMed1995

Understanding the factors behind the decision to purchase varying coverage amounts of long-term care insurance.

OBJECTIVE: This article examines the factors related to an individual's decision to purchase a given amount of long-term care insurance coverage. DATA SOURCE AND STUDY SETTING: Primary data analyses were conducted on an estimation sample of 6,545 individuals who had purchased long-term care (LTC) insurance policies in late 1990 and early 1991, and 1,248 individuals who had been approached by agents but chose not to buy such insurance. Companies contributing the two samples represented 45 percent of total sales during the study year. STUDY DESIGN: A two-stage logit-OLS (ordinary least squares) choice-based sampling model was used to examine the relationship between the expected value of purchased coverage and explanatory variables that included: demographic traits, attitudes, risk premium, nursing home bed supply, and Medicaid program configurations. DATA COLLECTION: Mail surveys were used to collect information about individuals' reasons for purchase, attitudes about long-term care, and demographic characteristics. Through an identification code, information on the policy designs chosen by these individuals was linked to each of the returned mail surveys. The response rate to the survey was about 60 percent. PRINCIPAL FINDINGS: The model explains about 47 percent of the variance in the dependent variable-expected value of policy coverage. Important variables negatively associated with the dependent variable include advancing age, being married, and having less than a college education. Variables positively related include being male, having more income, and having increasing expected LTC costs. Medicaid program configuration also influences the level of benefits purchased: state reimbursement rates and the presence of comprehensive estate recovery programs are both positively related to the expected value of purchased benefits. Finally, as the difference between the premium charged and the actuarially fair premium increases, individuals buy less coverage. CONCLUSIONS: An important finding with implications for policymakers is that changes in Medicaid policy affect the decisions of consumers regarding the acquisition of private LTC policies as well as the level of protection chosen. This is particularly important to states interested in pursuing public-private partnerships in long-term care financing.

Actuarial Analysis↗
PubMed1995

Medical outcomes of care for breast cancer among health maintenance organization and fee-for-service patients.

The quality of medical care provided to patients with different types of health insurance coverage has only recently begun to be evaluated. Very few studies have compared the process or outcome of care for cancer. Breast cancer is a good disease to use in medical effectiveness studies because it is relatively easy to diagnose with available technology and is treated effectively if detected early. The primary objectives of this study were to compare type of treatment, stage at diagnosis, and survival for female breast cancer patients newly diagnosed through fee-for-service with third-party coverage or health maintenance organization plans offered by the same medical practice during the same time period. Using a historical cohort design, data from a tumor registry were used to compare type of treatment, stage at diagnosis, and survival for 425 patients diagnosed from 1984 through 1992; 53.6% were members of a health maintenance organization and 46.4% used a variety of fee-for-service plans. Overall, there was no difference between the two groups in type of treatment, stage at diagnosis, or survival. Using fee-for-service as the reference group, Cox regression analysis showed that the unadjusted mortality rate ratio for survival was 0.66 (95% confidence interval = 0.432-1.020), and the rate ratio adjusted for age, race, and stage was 0.80 (95% confidence interval = 0.505-1.257). It was concluded that, despite differences in the type of health insurance coverage, there do not appear to be systematic differences in medical outcomes for breast cancer among women who are treated by the same medical care provider. These findings are of interest in the context of the rapidly changing organization of medical care with its implications for clinical practice and for the quality of care offered to patients with different types of medical insurance coverage.

Adult↗
PubMedDate not supplied

Unmet need for therapy services, assistive devices, and related services: data from the national survey of children with special health care needs.

OBJECTIVE: To estimate the prevalence of unmet needs for therapy services, vision and hearing care or aids, mobility aids, and communication aids and to investigate the association between predisposing, enabling, need, and environmental factors and unmet needs. METHODS: Using the National Survey of Children with Special Health Care Needs, we generated national prevalence estimates and performed bivariate and logistic analyses, accounting for the complex survey design. RESULTS: Nationally, the prevalence of unmet needs ranged from 5.8% among children with special health care needs (CSHCN) with a reported need for vision care or glasses to 24.7% among CSHCN with a reported need for communication aids. In logit analyses, CSHCN without insurance coverage were significantly more likely to have a reported unmet need for therapy services (adjusted odds ratio [OR]: 2.08, confidence interval [CI]: 1.39-3.12), vision care or glasses (OR: 3.94, CI: 2.64-5.86), and mobility aids (OR: 5.17, CI: 1.86-14.37). Children in families at or below 100% of the federal poverty level were significantly more likely to have a reported unmet need for vision care or glasses (OR: 4.51, CI: 2.86-7.12) and hearing aids or hearing care (OR: 3.61, CI: 1.70-7.65). For each of the services studied, more-severely limited children were significantly more likely to have an unmet need reported. CONCLUSION: Our findings demonstrate that a minority of CSHCN have unmet needs for therapy services, assistive devices, and related services. Parents of children with more-severe ability limitations were more likely to report having unmet needs. Our findings highlight the importance of insurance coverage in ensuring access to therapy services, assistive devices, and related services.

Adolescent↗
PubMed2000

Financing adolescent health care: the role of Medicaid and CHIP.

Financing health care for adolescents involves a combination of public and private sources of payment and, in the public sector, a combination of insurance coverage and categorical programs. In recent years, the importance of health insurance coverage has increased along with the potential for insuring more adolescents. Medicaid and the new State Children's Health Insurance Program (CHIP) offer numerous options for reducing the proportion of uninsured adolescents and for increasing adolescents' access to necessary health care. This article explores the potential of Medicaid and CHIP for meeting adolescents' needs, the extent to which they have done so already, and the gaps or missing links that remain. It also reviews issues that cut across funding sources related to managed care, consent, and confidentiality.

Adolescent↗
PubMedDate not supplied

Tax subsidies for health insurance: costs and benefits.

The continued rise in the uninsured population has lead to considerable interest in tax-based policies to raise the level of insurance coverage. Using a detailed microsimulation model for evaluating these policies, we find that while tax subsidies could significantly increase insurance coverage, even very generous tax policies could not cover more than a sizable minority of the uninsured population. For example, a generous refundable credit that costs $13 billion per year would reduce the ranks of the uninsured by only four million persons. We also find that the efficiency of tax policies, in terms of the cost per newly insured, inevitably would fall as more of the uninsured were covered.

Cost-Benefit Analysis↗
PubMed2001

Avoiding health insurance crowd-out: evidence from the Medicare as secondary payer legislation.

The cost of expanding health insurance coverage increases when people who would otherwise purchase insurance obtain public coverage. This paper investigates the effects of one of the first efforts to target insurance benefits to the most needy, the 1982 medicare as secondary payer (MSP) provisions. We find strong evidence of low compliance with the MSP both in terms of medical bill payments (payment compliance) and employer-sponsored insurance coverage (coverage compliance). We estimate payer compliance at approximately 33%. Coverage compliance is lower, at under 25%. We find weak evidence that the MSP caused older workers to shift toward MSP-exempt jobs.

Aged↗
PubMed2005

The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.

Both the costs and benefits associated with extending health insurance coverage depend on the extent and exact ways in which health insurance affects the utilization of medical care. We review the literature relating to such effects with the goal of informing researchers interested in simulating the impact of policy initiatives aimed at achieving universal coverage. Overall, this literature is quite consistent in finding significant effects of insurance on all types of utilization. Insurance coverage increases outpatient utilization by roughly 1 visit per year for children and between 1 and 2 visits for adults. For both children and adults, these visits are associated with an increased receipt of preventive care. Insurance coverage also increases inpatient utilization for children and adults; for children, there is some evidence that insurance coverage reduces ambulatory care sensitive hospital admissions.

Adolescent↗
PubMed2003

Summary health statistics for U.S. children: National Health Interview Survey, 1999.

OBJECTIVES: This report presents statistics from the 1999 National Health Interview Survey (NHIS) on selected health measures for children under 18 years of age, classified by sex, age, race/ethnicity, family structure, parent's education, family income, poverty status, health insurance coverage, place of residence, region, and current health status. The topics covered are asthma, allergies, learning disability, attention deficit disorder, use of medication, respondent-assessed health status, school-loss days, usual place of medical care, time since last contact with a health care professional, selected health care risk factors, and time since last dental contact. SOURCE OF DATA: The NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the National Center for Health Statistics, Centers for Disease Control and Prevention, and is representative of the civilian noninstitutionalized population of the United States. Basic information is collected during face-to-face interviews with adults present at the time of interview. Information about children is collected about one randomly selected child per family in face-to-face interviews with an adult proxy respondent familiar with the child's health. SELECTED HIGHLIGHTS: In 1999 most U.S. children under 18 years of age enjoyed excellent or very good health (83%). However, 12% of children had no health insurance coverage, and 6% of children had no usual place of medical care. Eleven percent of children had ever been diagnosed with asthma. An estimated 7% of children 3-17 years of age had a learning disability, and an estimated 6% of children had Attention Deficit Disorder (ADD). Lastly, 9% of children in single mother families had two or more visits to an emergency room in the past year, compared with 4% of children in two parent families.

Absenteeism↗
PubMed2003

Welfare reform, labor supply, and health insurance in the immigrant population.

Although the 1996 welfare reform legislation limited the eligibility of immigrant households to receive assistance, many states chose to protect their immigrant populations by offering state-funded aid to these groups. I exploit these changes in eligibility rules to examine the link between the welfare cutbacks and health insurance coverage in the immigrant population. The data reveal that the cutbacks in the Medicaid program did not reduce health insurance coverage rates among targeted immigrants. The immigrants responded by increasing their labor supply, thereby raising the probability of being covered by employer-sponsored health insurance.

Adolescent↗
PubMed2003

Coverage gaps for Medicaid-eligible children in the wake of federal welfare reform.

Using data from the National Survey of America's Families, this paper examines insurance coverage changes for Medicaid-eligible citizen children between 1997 and 1999, early in the implementation of federal welfare reform. More than 20 million children qualified for Medicaid, but many were uninsured. Insurance coverage deteriorated for eligible children between 1997 and 1999, particularly for those who also qualified for cash assistance; this deterioration in coverage was largely due to dramatic declines in cash assistance participation. This paper shows that following federal welfare reform, states have faced new challenges reaching and enrolling the growing numbers of eligible children who are not connected with the welfare system.

Adolescent↗
PubMed1984

Insurance plan effects on dental provider treatment patterns for elderly patients. An experimental economics approach.

Three hundred forty-six dentists, randomly selected from the population of Washington State Dental Association members, volunteered to participate in a controlled experiment of treatment planning for elderly patients. Experimental oral health problems were designed that conform to the prevailing actual distribution of dental and related systemic disease among the elderly population of the United States. Each volunteer dentist constructed two treatment plans for the presenting dental problem: 1) a treatment plan to optimize oral health, ignoring the hypothetical patient's financial status and insurance coverage; and 2) a treatment plan given the particular dental insurance plan and patient financial status incorporated in the case. Results suggest that increasingly comprehensive insurance coverage does not necessarily lead to uniform, monotonic increases in total dental expenditures. Rather, the incremental substitution of different services for one another appears to be the dominant effect of increased coverage, with the singular exception of coverage for fixed prosthodontia . The key implication of these findings is that careful design of improved insurance benefit plans for the elderly could widen the range of dental services provided without necessarily increasing total treatment cost.

Aged↗