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PubMed2005

The devil may be in the details: how the characteristics of SCHIP programs affect take-up.

In this paper, we explore whether the specific design of a state's program has contributed to its success in meeting two objectives of the Children's Health Insurance Program (SCHIP): increasing the health insurance coverage of children in lower income families and doing so with a minimum reduction in their private health insurance coverage (crowd-out). In our analysis, we use two years of Current Population Survey data, 2000 and 2001, matched with detailed data on state programs. We focus on two populations: the eligible population of children, broadly defined--those living in families with incomes below 300 percent of the federal poverty line (FPL)--and a narrower group of children, those who we estimate are eligible for Medicaid or SCHIP. Unique state program characteristics in the analysis include whether the state plan covers families; whether the state uses presumptive eligibility; the number of months without private coverage that are required for eligibility; whether there is an asset test; whether a face-to-face interview is required; and specific outreach activities. Our results provide evidence that state program characteristics are significant determinants of program success.

Child↗
PubMed1996

Insurance for autosomal dominant polycystic kidney disease patients prior to end-stage renal disease.

There recently has been substantial dialogue about access to health insurance for Americans. This discussion has highlighted the issues of pre-existing diseases and portability as barriers to adequate health insurance coverage. For these reasons we decided to investigate the issues relating to health insurance and life insurance coverage experienced by patients with autosomal dominant polycystic kidney disease (ADPKD). A questionnaire-based study was conducted. Two hundred thirty-eight of 354 subjects responded. There was no significant difference in gender, age, number of children, or level of renal function between responders and nonresponders. Twenty-eight of the 238 respondents had eight-stage renal disease and were eligible for Medicare; these patients were not used in the analyses relating to health insurance, but were used in the analyses relating to life insurance. Although 87% of the ADPKD patients were concerned about the availability of health insurance, 88% were currently insured. Eight-three percent of subjects with health insurance obtained it through their own or their spouse's employer. Of those individuals with employer-based health insurance who were aware of their ADPKD, only 25% informed their employer and 35% informed their insurer at the start of coverage. Fifty-seven percent of those with employer-based health insurance had this availability determine their job choice and 37% stayed in the job because of health insurance. Thirty percent of the subjects had previously been denied health insurance. Although subjects were less concerned about life insurance, many of the same types of issues and factors were present. Thus, the current lack of universal health care in this country creates anxiety and difficulties for patients with ADPKD. The effect of a pre-existing condition and the lack of portability resulted in denials, work choice limitation, and unwillingness to share health information for this patient population with a hereditary, systemic disease.

Adult↗
PubMed2005

Medicaid: Medicaid: eligibility--2005. End of Year Issue Brief.

Medicaid, a joint federal-state program started in 1965 as Title XIX of the Social Security Act, provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. In 2003, Medicaid provided health care insurance to approximately 40.2 million low-income Americans. That same year, 45 million Americans had no health insurance at all. In order to reduce the number of uninsured people in the United States, state legislators have introduced hundreds of bills over the past decade to expand health insurance coverage to low-income citizens. Health insurance has been extended for low-income children through Medicaid expansions, the State Children's Health Insurance Program (SCHIP) and other medical assistance programs. States, in partnership with the federal government, have also made it easier for disabled individuals to qualify for Medicaid through Ticket-to-Work legislation (which allows individuals with disabilities to remain in the workforce and keep their Medicaid coverage). They also have expanded coverage for senior citizens, especially for their prescription drug needs through Medicaid Pharmacy Plus waivers. In fact, from 1997 to 2003, monthly Medicaid enrollment rose from 31.2 million to 40.6 million recipients.

Adult↗
PubMedDate not supplied

Design of a survey to inform state health decision making: a collaborative effort.

BACKGROUND: The North Carolina Health Profile (NCHP), a statewide telephone survey, was introduced as part of the state's Health Policy Information Project aimed at enhancing the use of health data for state policy decision making and program management. A key factor in the creation of the NCHP was a collaboration between the State Center for Health Statistics and the Survey Research Unit at the University of North Carolina at Chapel Hill. The purpose of this article is to describe our partnership, the development of the survey design, and the dissemination of survey results. METHODS: Three designs were considered during the planning and development of the survey. The final design consisted of a random digit dialing sample of 2,400 households in the state's noninstitutionalized population. The questionnaire was comprised of an adult module (addressing adult health care use and insurance coverage), a child module (addressing health care use and insurance coverage of children ages 0-17 years), and a young child module (addressing child development and safety for children ages 0-5 years). RESULTS: Several statistical briefs, a report, a public dataset, and accompanying public use documentation were prepared for a variety of audiences, including state legislative committees and commissions, state agencies, and advocacy groups. DISCUSSION: We learned several lessons in our research and practice partnership including the need for collaboration between data creators and users, for addressing obstacles in soliciting policy information needs, and for prioritization in meeting information needs.

Cooperative Behavior↗
PubMed2002

Chronic illness among poor children enrolled in the temporary assistance for needy families program.

OBJECTIVES: This study assessed chronic child illness among recipients of Temporary Assistance for Needy Families (TANF) benefits and poor families not receiving benefits. METHODS: Data from the 1998 National Health Interview Survey were used to examine chronic child illness, enrollment in TANF, health insurance status, and selected access indicators. RESULTS: One quarter of TANF-enrolled children had chronic illnesses. Unenrolled children were 3 times as likely as TANF-enrolled children to be uninsured. Among the chronically ill, 31.7% of unenrolled and 14.3% of enrolled children experienced gaps in insurance coverage that were associated with access barriers. CONCLUSIONS: Welfare policies should consider the effects of chronic illness and gaps in insurance coverage on the health of poor children.

Adolescent↗
PubMed2003

Mold insurance: crafting coverage for a spreading problem.

Mold contamination is a growing concern for homeowners in terms of both physical health and insurance. Health experts, although they concede that exposure to mold can cause respiratory illnesses, are calling for further research into other mold-related health effects and for development of standards for mold sampling and data analysis. The insurance industry is grappling with how---and whether---to provide coverage for household damage caused by mold, while some state and federal legislators are working to pass laws regarding mold testing and insurance.

Air Pollution, Indoor↗
PubMed2005

Delayed and forgone care for children with special health care needs in New York State.

OBJECTIVE: To identify characteristics associated with delayed/forgone care for children with special health care needs (CSHCN) in New York State (NYS) as reported by their parents. METHODS: Data come from NYS participants in the 2000-2002 National Survey of Children with Special Health Care Needs. Data were analyzed using weighted bivariate and multivariate regression models. The dependent variable was report of delayed/forgone routine health care. Independent variables included illness characteristics, potential and actual access to care, and provider care characteristics. RESULTS: In NYS, 8.4% reported delayed/forgone health care for their child. Parents of children with delayed/forgone care were more likely to report that their child was uninsured (adjusted odds ratio [aOR] 3.8, 95% confidence interval [CI] 1.3-11.8), had experienced interrupted health insurance (aOR 3.9, 95% CI 1.5-9.7), or their child's insurance was not adequate for CSHCN (aOR 3.6, 95% CI 1.4-9.1). Further, these parents were more likely to report that providers never spend adequate time (aOR 6.3, 95% CI 1.2-34.4), provide sufficient information (aOR 8.0, 95% CI 2.5-25.0), act as partners in care (aOR 6.7, 95% CI 2.3-19.7), or display cultural sensitivity (aOR 5.4, 95% CI 1.2-24.3). CONCLUSIONS: An estimated 40,771 NYS CSHCN experience delayed/forgone routine health care. Their families report two noteworthy barriers: inadequate or discontinuous insurance coverage and poor communication with health-care providers. Access to care for CSHCN can be improved by increasing consistent comprehensive insurance coverage and increasing sensitivity in relationships between health care providers and families of CSHCN.

Adolescent↗
PubMedDate not supplied

[Insurance and coverage: two critical topics in health care reforms].

The goal of health for all in the year 2000, which was established at Alma Ata more than two decades ago, has led countries in Latin America and the Caribbean to adopt health sector reforms aimed at extending health coverage to each and every individual citizen. Whereas much has come about as a result of reform policies in the way of theory and legislation, in practice the goals that were established are far from attained, and many countries show large gaps in theoretical coverage on the one hand, and true coverage on the other. This is largely due to organizational features and other "endogenous" characteristics of the various countries' health systems, as well as to "exogenous" factors in the political, macroeconomic, social, epidemiologic, and cultural spheres. This documents takes a close look at the different types of health systems that are currently operating in countries of the Region and their impact on sources of health insurance and health coverage for individuals living in those countries. The end of the article focuses on the different strategies adopted by the countries in an effort to extend health coverage, which in some cases involve policies targeting the most vulnerable social groups.

Caribbean Region↗
PubMed2005

Effects of the State Children's Health Insurance Program Expansions on children with chronic health conditions.

OBJECTIVE: To estimate the effects of the State Children's Health Insurance Program (SCHIP) expansions on insurance coverage, use of health care services, and access to care for children with chronic health conditions. METHODS: The primary source of data was the National Health Interview Survey. Children with chronic health conditions were identified primarily through reported diagnoses of common chronic conditions (eg, asthma, attention-deficit disorder, mental retardation, Down syndrome, cerebral palsy, muscular dystrophy, sickle cell disease, diabetes, arthritis, heart disease) and on the presence of activity limitations caused by a health problem lasting at least 12 months. We examined changes in a broad array of outcomes for children with chronic health conditions who gained eligibility under SCHIP or who were already eligible for coverage under Medicaid, comparing the periods before and after implementation of the program. Changes for these treatment groups were compared with children with slightly higher incomes, who should not have been affected by the eligibility expansions. Comparisons were made with adjustment for child, family, and other characteristics that might have independent effects on the outcomes of interest. Outcomes included health insurance coverage, use of general and specialty services, access to care, and out-of-pocket spending on health care. Selected analyses were conducted for children not identified as having chronic health conditions. RESULTS: The SCHIP expansions resulted in a 9.8 percentage point increase in the proportion of children with chronic conditions reporting public insurance and a 6.4 percentage point decline in the proportion uninsured. Unmet need for health care decreased by 8 percentage points, with most of the decline found for dental care. Increases in specialist, eye care, and dental visits and decreases in out-of-pocket spending and emergency-department and mental health visits were observed but did not meet standards of statistical significance. Estimated reductions in unmet need were greater for children with chronic conditions than for other children. CONCLUSIONS: Recent expansions in public insurance eligibility under SCHIP have improved coverage for children with chronic conditions, with selected improvements in access to care. However, some eligible children with chronic conditions remain uninsured, and the impact on access to care and service use were limited. Additional progress may require targeted outreach to children with chronic conditions and improvements in Medicaid and SCHIP service-delivery systems. Given the current fiscal environment and the fact that children with chronic conditions have not generally been protected from cutbacks, the recent progress documented in this study may be reversed.

Child↗
PubMedDate not supplied

Covering the uninsured: how much would it cost?

To provide benchmarks for evaluating the costs of alternative proposals to provide insurance coverage for the uninsured, this study presents two sets of cost estimates derived from medical spending patterns of lower- or middle-income people with private insurance plans and those of people with public insurance coverage during 1996-1998. The analysis suggests that the uninsured would use dollar 33.9-dollar 68.7 billion (in 2001 dollars) in additional medical care if they were fully insured. An increase in medical spending of this range would increase total health care spending by 3-6 percent and would raise health care's share of GDP by less than one percentage point.

Health Care Costs↗
PubMed2001

Down and out in America: children and health care.

One of the worst forms of inequality in the health care field is the inequality suffered by children. In 1996, over 14.5 million children lived in poverty in the United States. Children who live in poverty are less likely to have health insurance and have less access to health care and thus are more likely to suffer negative outcomes in health care. The Congress of the United States in 1997 enacted the State Children's Health Insurance Program (S-CHIP) to expand health insurance coverage for children. This paper examines the major features of the program, actions undertaken by the state governments under this program to expand health insurance coverage for children, and provides some preliminary analysis of the potential positive and negative impact of the program.

Adolescent↗
PubMedDate not supplied

Effect of Medicare coverage on use of invasive colorectal cancer screening tests.

BACKGROUND: Colorectal cancer is the second leading cause of cancer death in the United States. Screening for colorectal cancer is now widely recommended but underused. Lack of insurance coverage for screening tests may be one reason patients do not undergo these procedures. OBJECTIVE: To determine the effect of Medicare reimbursement on utilization rates of invasive screening tests. Use of fecal occult blood testing was not studied before 1998. METHODS: We performed a retrospective analysis of ambulatory claims data for Washington State Medicare beneficiaries in 1994, 1995, and 1998. We determined the proportion of patients undergoing diagnostic and screening flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema in 1994, 1995, and 1998 and the proportion receiving fecal occult blood testing in 1998. RESULTS: Use of diagnostic and screening colon tests was low in all years. Fewer than 6% of beneficiaries received any colon test, and fewer than 4% received a screening test. Although more patients underwent diagnostic testing after Medicare coverage began, use of screening tests did not significantly change (odds ratio, 0.99; 95% confidence interval, 0.97-1.01 comparing 1994 and 1998 [P =.33]). Women, individuals older than 80 years, and nonwhite patients were statistically significantly less likely to be screened in all 3 years (P<.001). In 1998, fewer than 7% of patients underwent fecal occult blood testing, with men and nonwhites statistically significantly less likely to have this test (P<.001). CONCLUSIONS: Colorectal cancer screening tests are underused in the Washington State Medicare population, and insurance coverage for these tests did not substantially affect utilization rates in the period studied.

Aged↗
PubMed2004

Is it really worse to have public health insurance than to have no insurance at all? Health insurance and adult health in the United States.

Using prospective cohort data from the 1979 National Longitudinal Survey of Youth, this study examines the extent to which health insurance coverage and the source of that coverage affect adult health. While previous research has shown that privately insured nonelderly individuals enjoy better health outcomes than their uninsured counterparts, the same relationship does not hold for those publicly insured through programs such as Medicaid. Because it is unclear whether this finding reflects a true causal relationship or is in fact due to selection bias on socioeconomic status and health, previous estimates of the contribution of health insurance to inequities in health may have been biased. This study attempts to disentangle these competing hypotheses of causation or selection bias by using fixed effects models with sibling clusters to corroborate--or contradict--the results of a conventional OLS regression. By controlling for unobserved factors shared by siblings, such as parental genetic influences, sibling models estimate health insurance effects that are less affected by selection bias. Findings suggest that, among the US. birth cohorts of 1957 to 1961, the negative relationship between public health insurance and health is not causal, but rather due to prior health and socioeconomic status. Conversely, the lack of health insurance coverage has a strong cumulative negative impact on adult health.

Adult↗
PubMedDate not supplied

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↗
PubMed2006

Characteristics of U.S. youths with serious emotional disturbance: data from the National Health Interview Survey.

OBJECTIVE: Although it is estimated that serious emotional disturbance affects 9 to 13 percent of children and adolescents in the United States, there are few national data on the characteristics of this group. METHODS: This study used data for 13,579 youths from the 2001 National Health Interview Survey (NHIS) to describe the sociodemographic features and insurance coverage of youths with serious emotional disturbance living in the United States. Youths with serious emotional disturbance were identified through their scores on the Strengths and Difficulties Questionnaire, which was added to the NHIS in 2001. RESULTS: A large majority of youths with serious emotional disturbance were white and had income at 200 percent of the poverty level or higher. About 40 percent of youths with serious emotional disturbance had private insurance coverage, whereas Medicaid and the State Children's Health Insurance Program provided coverage for about a third of youths with serious emotional disturbance. CONCLUSIONS: Although Medicaid is an important payer of mental health services for youths with serious emotional disturbance, private insurance is still the primary source of health coverage for youths with serious emotional disturbance and for the overall population of youths.

Adolescent↗
PubMed1998

The role of state maternal and child health programs in the issue of newborn discharge.

OBJECTIVES: Since dramatically shortened newborn hospitalization has shifted the focus of care from the hospital, a central policy question has become how to assure a system of care that extends into the home and community. The objective of this study was to examine the role of the state Maternal and Child Health Title V programs in the assessment of the issue of newborn discharge, the development of policies, and the assurance of appropriate care. METHOD: The director or their designee in all 50 states and the District of Columbia participated in a structured telephone interview lasting 30-60 minutes. RESULTS: Twenty-eight states reported new or previously implemented mandates for 48 hours of private insurance coverage for postpartum hospitalization. Only 6 states reported mandates concerning private insurance coverage of inpatient services, but 20 states reported mandates for postdischarge services. In the assessment function, only 18 maternal and child health (MCH) programs reported that they had undertaken specific studies on the effects of discharge timing in their states. In policy development, 18 of the 51 respondents reported that the MCH program initiated newborn discharge discussions, 23 reported that the agency participated in discussions, and 10 indicated that they did not participate. In assurance, 29 programs reported that they had taken action to provide technical assistance to local communities in developing follow-up systems. The relationship between the performance of core functions and the development of specific discharge policies in the state was minimal. CONCLUSIONS: The MCH programs appear to have played varied, but often limited, roles in the development of discharge policies. It is essential for MCH programs to engage actively in the policy-making process. But in the political environment surrounding newborn discharge policy, where laws and regulations consistent with the well-being of infants and mothers were being enacted, the limited MCH program roles may have been appropriate. Arguing against this conclusion, however, is that only 15 programs believed they had been effective and only 19 were satisfied with the discharge policies in their states, which suggests that a more proactive role may be necessary.

Aftercare↗
PubMed2000

Health insurance in South Africa: an empirical analysis of trends in risk-pooling and efficiency following deregulation.

This paper reports an empirical investigation into the pattern of private health insurance coverage in South Africa before and after deregulation of the health insurance industry. More specifically, we sought to measure trends in risk-pooling over the period 1985-95, and to assess the impact of risk pooling on the costs of health insurance cover over this period. South African mutual health insurers (Medical Schemes) have existed for over 100 years, and have been regulated under a specific Act since 1967. Up until 1989, health insurers were required by law to community rate their premiums, and were not allowed to exclude high-risk enrolees from cover. In 1989 these regulations were removed, effectively allowing health insurers to risk-rate the cover which they provided, and exclude 'medically uninsurables'. Data were obtained from the office of the health insurance regulator (the Registrar of Medical Schemes) for the period 1985-95, and consisted of the statutory returns from all registered medical schemes for each year during the study period. Multiple regression methods were used to assess the determinants of changes in the risk pools of insurers, and their costs. Both cross-sectional and longitudinal models were estimated. Unadjusted data suggest changes in risk-pooling since the deregulation period after 1985. Health insurers with open enrolment had worse than average risk profiles in the 1980s, but this reversed by the early 1990s, leaving them with significantly better risk profiles by 1995. Worsening risk profiles were associated with decreasing fund size, higher loss-ratios and past premium increases. Most models showed that risk rating of premiums was consistently associated with higher premiums, after adjustment for risk, quality, scale and other environmental differences between insurers. Likely explanations include the additional costs required for marketing and underwriting risk-rated policies, insufficient incentives to use cost-control techniques, and higher levels of moral hazard associated with diminished risk-pooling. Current re-regulation of risk-pooling within medical schemes may thus improve both equity and efficiency of private health care cover.

Actuarial Analysis↗