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PubMed1997

Socio-economic differences in general practitioner and outpatient specialist care in The Netherlands: a matter of health insurance?

Equal treatment for equal needs, irrespective of socio-economic position, is a major issue in many countries. Although in the Netherlands differences in utilization of health care between population groups are less pronounced than in most other countries, some differences by socio-economic position do exist. Controlling for health status, individuals with a high socio-economic status have a higher probability of outpatient contacts with a specialist, but a lower probability of general practitioner contacts, compared with those with a low socioeconomic status. In this cross-sectional study, we studied whether socio-economic differences in GP and outpatient specialist care utilization that exist after health status is taken into account could be explained by different aspects of health insurance. The study population, in which people with asthma and chronic obstructive pulmonary disease (COPD), diabetes mellitus, severe back complaints, and heart diseases are overrepresented, consists of 2867 respondents. Multivariate analyses show that the socio-economic differences in outpatient specialist contacts cannot be explained by differences in health insurance, whereas differences in general practitioner contacts can partially be explained by the fact that individuals with higher socio-economic status more often have a private (instead of public) insurance. This is not owing to differences in deductible or insurance coverage between public and private insurance, but is more likely to be caused by differences in regulatory aspects between these two insurance schemes (such as the stronger gate-keeper role of the general practitioner in the public insurance scheme.

Adult↗
PubMed2000

Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals.

OBJECTIVE: To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies. DESIGN: A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies. SETTING: A large regional public hospital, New South Wales, Australia. PARTICIPANTS: The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997. RESULTS: After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies. IMPLICATIONS FOR PRACTICE: Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Decision Making↗
PubMed2003

A comparison of health insurance in Slovenia and Croatia.

Before Croatia and Slovenia became independent in 1991, they had similar health systems. They have generally taken the same reform path since then, but have also travelled in opposite directions on occasions. Of particular relevance here, both countries established quasi-government agencies to administer a new national scheme of compulsory health insurance in 1993. However, Slovenia's compulsory scheme involved much larger copayments, and a parallel voluntary insurance scheme was created mainly to cover them. In 2002, Croatia increased copayments and introduced a voluntary insurance scheme almost identical to that of Slovenia's. To complete the circle, Slovenia has announced it intends to abandon the use of voluntary insurance for copayments, and reduce the level of copayments for its compulsory scheme. This paper describes and compares the two insurance systems, and I argue that there has been considerable success in difficult circumstances. However, the experiences reinforce aspects of design that seem to be generally relevant: the need to make use of consumers' informed opinions, to recognise and then redress a lack of experience of optional approaches among many of those making decisions about health insurance, to define and apply a rigorous evaluation framework that includes estimating peoples total costs for health care, to emphasise the long term, to identify and ensure there is transparency of vested interests, and to use the financial power of the dominant government insurer to encourage and reward improvements in clinical practice.

Bed Occupancy↗
PubMed2003

Relationship between health insurance and medical care for patients hospitalized with human immunodeficiency virus-related Pneumocystis carinii pneumonia, 1995-1997: Medicaid, bronchoscopy, and survival.

In the late 1980s, Medicaid-insured human immunodeficiency virus (HIV)-infected patients with Pneumocystis carinii pneumonia (PCP) were 40% less likely to undergo diagnostic bronchoscopy and 75% more likely to die than were privately insured patients, whereas rates of use of other, less resource-intensive aspects of PCP care were similar. We reviewed 1395 medical records at 59 hospitals in 6 cities for the period 1995-1997 to examine the impact of insurance status on PCP-related care. Medicaid patients were only one-half as likely to undergo diagnostic bronchoscopy as were privately insured patients, yet we found no evidence that mortality was greater among patients who received empirical treatment. The bronchoscopy rates were primarily related to patients' personal insurance status. A weaker hospital-level effect was seen that was related to hospitals' Medicaid/private insurance case mix ratios. The situation has evolved from one in which Medicaid coverage was associated with underuse of bronchoscopy and poorer survival among empirically treated persons with HIV-related PCP to one in which empirical therapy is effective in treating this disease and expensive diagnostic procedures may be overused for privately insured patients.

AIDS-Related Opportunistic Infections↗
PubMed2005

Stimulant dosage and age, race, and insurance type in a sample of children with attention-deficit/hyperactivity disorder.

OBJECTIVE: The aim of this study was to examine the association of age, race, insurance, and other factors with the prescription of stimulant medications. METHODS: A retrospective chart review was conducted on 242 subjects, 4.8-19.8 years of age, treated in an urban referral center with a stable dose of stimulant medication for at least 6 months. Subjects were predominantly male (74.8%), African-American (52.9%), and insured by Medicaid (71.0%). The effects of age, race, insurance, gender, cognitive level, additional psychopharmacologic medications, and other factors on prescribed total daily dose (mg/day) and dose by weight (mg/kg/dose) were examined. RESULTS: Race and insurance type together were associated with specific patterns of stimulant dosage, with higher dosing seen in Medicaid-insured non-African-American children and in privately insured African-American children. Total daily dose increased with age; however, there was an inverse relationship between age and dose by weight. There were no significant associations of gender, cognitive level, use of additional psychopharmacological medications, or other factors with total daily dose or dose by weight. CONCLUSIONS: The sociocultural factors of race and insurance type were related to dosing of stimulant medications in children. Total daily doses increased with age, while younger children were treated with higher weight-based doses. Attention to these factors should be given in the titration of stimulant medications in the treatment of ADHD. Other factors, including gender, had no specific association.

Adolescent↗
PubMed1999

Genetic testing, Alzheimer disease, and long-term care insurance.

Patients with Alzheimer Disease (AD) often need long-term care, which is poorly covered by private or governmental health insurance. Private long-term care (LTC) insurance is increasingly being marketed to provide some financial support for long term care. LTC insurance does cover AD, but the insurers will not sell policies to people who have already been diagnosed with AD. As a result, LTC insurance might be particularly attractive to individuals who are at heightened risk for developing AD. This makes the issues surrounding predictive genetic testing for AD and the use of test results in determining insurance premiums and eligibility of great concern to patients, clinicians, insurers, ethicists, and patient advocate groups. The paper examines the complexities of these issues.

Alzheimer Disease↗
PubMed1998

Gaps and transitions in health insurance: what are the concerns of women?

This is a study of women's health insurance that makes both disaggregated and longitudinal comparisons between men and women to identify and describe gaps and sources of insecurity that are important for women. Income and family status are more important than gender in explaining health insurance differences. In many respects, the health insurance experiences of single women are more similar to those of single men than those of married women. Although married women often depend on their husbands for employer-sponsored insurance, the health insurance of married men and women is otherwise quite similar. Married women are at no greater risk of losing employer-sponsored insurance than married men, and married women experience fewer gaps and changes in coverage than single women (and single men). An expansion of coverage to all poor and uninsured adults would benefit more women than men by a small margin, despite the focus of Medicaid on low-income women. The married uninsured are concentrated just above the poverty line and have a big stake in whether public coverage programs extend above poverty. The main issue for women at higher income levels, especially for single women who cannot fall back on a spouse for coverage, is the danger of losing health insurance as a result of changes in employment.

Adult↗
PubMed1996

The extent of private and public health insurance coverage among adult Hispanics.

Data from the Health and Retirement Survey reveal extremely low levels of health insurance coverage among Hispanics and, especially, among Mexican Americans. The data reveal that this lack of insurance is associated with lower rates of employer-based and privately purchased coverage. Even after controlling for a large number of insurance-related factors, Hispanics have rates of health insurance coverage that are lower than those of either non-Hispanic blacks or whites. This serious lack of health insurance coverage among preretirement-age Hispanics has serious implications both for health, because the lack of insurance represents a major barrier to health care, and for the adequacy of retirement coverage, because private insurance represents an important supplement to Medicare.

Adult↗
PubMed1998

Life transitions and health insurance coverage of the near elderly.

OBJECTIVES: This study addresses three issues. (1) What are demographic wealth, employment, and health characteristics of near-elderly persons losing or acquiring health insurance coverage? Specifically, (2) what are the effects of life transitions, including changes in employment status, health, and marital status? (3) To what extent do public policies protect such persons against coverage loss, including various state policies recently implemented to increase access to insurance? METHODS: The authors used the 1992 and 1994 waves of the Health and Retirement Study to analyze coverage among adults aged 51 to 64 years. RESULTS: One in five near-elderly persons experienced a change in insurance coverage from 1992 to 1994. Yet, there was no significant change in the mix of coverage as those losing one form of coverage were replaced by others acquiring similar coverage. CONCLUSIONS: Individuals whose health deteriorated significantly were not more likely than others to suffer a subsequent loss of coverage, due to substitution of retiree or individual coverage for those losing private coverage and acquisition of Medicaid and Medicare coverage for one in five uninsured. State policies to increase access to private health insurance generally did not prevent individuals from losing coverage or allow the uninsured to gain coverage. Major determinants of the probability of being insured were education, employment status of person and spouse, and work disability status. Other measures of health and functional status did not affect the probability of being insured, but had important impacts on the probability of having public coverage, conditional on being insured.

Death↗
PubMed2001

Use of health services by insurance status among children with asthma.

OBJECTIVES: It is well known that asthmatic children receiving Medicaid use the emergency department (ED) more frequently than otherwise-insured asthmatic children. However, the extent to which this difference is attributable to provider characteristics, medication use, access to primary care, and symptomatology is poorly understood. These factors were explored as independent predictors of health care utilization. METHODS: Baseline data from a prospective cohort study of childhood asthma severity were used. Subjects were recruited from seven New England hospitals. Home interviews collected data on monthly symptoms, health care visits, insurance status, as well as sociodemographics and asthma-related risk factors (n = 804). Characteristics of providers' practices, board certifications, and asthma specialty were obtained from Folio's Medical Dictionaries for Connecticut and Massachusetts. RESULTS: After adjusting for frequency of asthma-related primary care visits, primary provider practice type, use of asthma specialist, age, gender, medication use, and symptomatology, Medicaid children still used the ED more frequently for asthma services than privately insured children (RR, 1.7; 95% CI, 1.1, 2.5). In general, race/ethnicity did not modify the relationship between insurance status and health care use, except that black children receiving Medicaid were 90% (95% CI, 0.0, 0.7) less likely to have had > or = 3 routine primary care visits for asthma in the previous year than black privately insured children. White children receiving Medicaid were 2.5 (95% CI, 1.0, 6.9) times more likely to use the ED for asthma than privately insured white children. CONCLUSIONS: The results suggest that enabling, structural, and need factors do not necessarily explain observed differences in pediatric asthma health care use by insurance status. Future investigation must explore other explanatory factors such as maternal attitudes and beliefs and patient-provider communication.

Black or African American↗
PubMed1987

Price elasticity and adverse selection in the demand for supplementary health insurance.

Probit regression estimates show the effects of the price of insurance, anticipated medical expenditures, and other factors on reported decisions about purchasing hypothetically offered supplementary insurance policies. The demand estimates can characterize how much supplemental insurance would be purchased under different tax policies affecting health insurance purchases. Although eliminating the current tax subsidy to insurance is shown to decrease demand, the results indicate a substantial demand for supplementary insurance even in the absence of present tax incentives. However, our results on adverse selection raise concerns about the potential stability of supplemental insurance markets.

Algorithms↗
PubMed2005

Welfare reform and health insurance of immigrants.

OBJECTIVE: To investigate the effect of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) on the health insurance coverage of foreign- and U.S.-born families headed by low-educated women. DATA SOURCE: Secondary data from the March series of the Current Population Surveys for 1994-2001. STUDY DESIGN: Multivariate regression methods and a pre- and post-test with comparison group research design (difference-in-differences) are used to estimate the effect of welfare reform on the health insurance coverage of low-educated, foreign- and U.S.-born unmarried women and their children. Heterogeneous responses by states to create substitute Temporary Aid to Needy Families or Medicaid programs for newly arrived immigrants are used to investigate whether the estimated effect of PRWORA on newly arrived immigrants is related to the actual provisions of the law, or the result of fears engendered by the law. PRINCIPAL FINDINGS: PRWORA increased the proportion of uninsured among low-educated, foreign-born, unmarried women by 9.9-10.7 percentage points. In contrast, the effect of PRWORA on the health insurance coverage of similar U.S.-born women is negligible. PRWORA also increased the proportion of uninsured among foreign-born children living with low-educated, single mothers by 13.5 percentage points. Again, the policy had little effect on the health insurance coverage of the children of U.S.-born, low-educated single mothers. There is some evidence that the fear and uncertainty engendered by the law had an effect on immigrant health insurance coverage. CONCLUSIONS: This research demonstrates that PRWORA adversely affected the health insurance of low-educated, unmarried, immigrant women and their children. In the case of unmarried women, it may be partly because the jobs that they obtained in response to PRWORA were less likely to provide health insurance. The research also suggests that PRWORA may have engendered fear among immigrants and dampened their enrollment in safety net programs.

Adolescent↗
PubMed2003

Birth outcomes and maternal morbidity in abused pregnant women with public versus private health insurance.

PURPOSE: To compare the effects of recent intimate partner abuse on maternal and infant health in publicly versus privately insured pregnant women. DESIGN: Exploratory descriptive analysis in 13 Massachusetts prenatal care sites from records of 2,052 women who had been screened during pregnancy for domestic violence. METHODS: Clinicians screened pregnant women for domestic violence using the Abuse Assessment Screen. After delivery, prenatal and birth outcome data and abuse screening results were extracted from medical records by project staff. Odds ratios were used to compare maternal and infant health indicators in abused and nonabused women. Data from women with public and private health insurance then were examined separately, using logistic regression to control for low education and single marital status while examining the odds of adverse maternal and infant outcomes in abused and nonabused women. FINDINGS: In the sample as a whole, recently abused women were more likely to be publicly insured and unmarried, to have less than 12 years of formal education, and to have medical and obstetrical complications. Parity, ethnic background, and infant birth outcomes did not differ in relation to abuse. In separate analyses for women with public and private health insurance, after controlling for marital status and education, abuse increased the odds of low infant Apgar scores, poor nutrition, hyperemesis, hypertension, and substance abuse in publicly insured women, and abuse increased the odds of poor nutrition and bleeding during pregnancy for privately insured women. CONCLUSIONS: The different correlates of abuse in publicly and privately insured women might be important for clinicians caring for these different populations. Screening for abuse and providing abuse-related services are indicated for pregnant women.

Adolescent↗
PubMed1995

Health insurance coverage and use of services among low-income elders: does residence influence the relationship?

This research uses a nationally representative sample of 1,425 low-income elders from the 1987 National Medical Expenditure Survey (NMES) to assess the independent and interaction effects of health insurance coverage and residence on the use of seven health care services: doctor visits, visits to other personnel, telephone contact, emergency room visits, overnight hospital stays, outpatient visits, and prescription medicines. It is hypothesized that (a) elders without insurance to supplement Medicare; (b) those who lived in nonmetropolitan areas use fewer health services; and (c) insurance status and residence interact to influence use of health services, with nonmetropolitan elders using fewer services than those living in metropolitan areas, regardless of insurance type. Using multivariate statistical analyses with both main effects and interaction term models, the data indicate that the type of insurance that low-income elders have is associated with their use of health services, and that residence has only modest effect. Individuals who have Medicaid, and to a lesser extent private supplements, use services more frequently than do those without supplements. Finally, despite the hypothesis, residence does not interact with insurance status in influencing use of services; the relationship between insurance and use of services does not vary across area of residence. The data suggest that the ability to pay, rather than supply constraints associated with nonmetropolitan areas, are of primary importance in determining health care use among low-income elders.

Aged↗
PubMed1991

Sports insurance and national governing bodies.

A postal survey was conducted of the attitudes and advice of Welsh governing bodies of amateur sports and their Cardiff-based clubs towards personal sports insurance. Information on 36 of the 39 sports surveyed (92%) was sufficient for analysis. Twenty-two of these 36 sports (61%) organized insurance at a national level, one at club level (3%) and 13 (36%) provided no insurance advice. Only 12 sports (33%) insisted on mandatory insurance cover. Many sportsmen and women are left to search for an appropriate insurance cover themselves or remain uninsured. Owing the lack of advice in 36% of cases it was decided to survey Cardiff-based insurance brokers to establish what type of policy they would recommend. Only 41% of the brokers were able to offer a suitable policy. Club policies recommended by the Central Council for Physical Recreation provide individuals with the same sports cover (but at a lower premium) as is available from a personal accident policy. However, cover is somewhat inadequate and may provide a false sense of security. Sports with mandatory sports insurance are not necessarily those with the highest risk of disabling injury.

Athletic Injuries↗
PubMed1999

[Health economic analysis of the effects of including complementary medicine in the benefit package of health insurance].

A randomized experiment was set up in which 7,500 policyholders of Switzerland's largest health insurance fund, Helvetia, were offered free supplementary insurance for complementary medicine for 3 years. This was meant to simulate a situation in which the experimental group had access to the full range of complementary medical treatments under their health insurance policies. The remaining policyholders in the scheme (670,000 people) formed the control group. A third group of policyholders who had taken out additional insurance for complementary medical services at their own expense is mentioned only in passing. The health insurer's cost and benefit data were analyzed to evaluate the effect of the offered free supplementary insurance for complementary medicine. In addition, a survey was carried out among random samples of subjects from the experimental group and from the control group using the 36-Item Short-Form Health Survey (SF-36) to examine the effects of including complementary medicine on people's subjective state of health. The analysis of the cost data showed that subjects in the experimental group used complementary medicine in addition to mainstream medical services. It became also clear that alternative medical treatments were given in combination with orthodox medicine; less than 1% of the experimental group used exclusively alternative medical services. However, as only a very small percentage of the experimental subjects (6.6%) took advantage of complementary medicine, no significant impact on overall health cost could be inferred. On the other hand, multiple regressions showed that the use of complementary medicine had a greater effect on the treatment costs than sex, age or language region. Neither at the beginning nor the end of the experiment were any significant differences noted in the scales of the SF-36 between the experimental and the control group; nor did multiple regressions reveal any effects on subjects' state of health due to the inclusion of complementary medicine in the basic insurance cover. This study was presented in the media and at a public hearing of the Swiss National Science Foundation. It triggered numerous valuable discussions. The study design and the conclusions were not left uncontested.

Adult↗
PubMed1995

Relationship between procedures and health insurance for critically ill patients with Pneumocystis carinii pneumonia.

The objective of the present study was to assess the association between type of health insurance coverage and use of diagnostic tests and therapies among patients with AIDS-related Pneumocystis carinii pneumonia (PCP). Fifty-six private, public, and community hospitals in Chicago, Los Angeles, and Miami were selected for the study, and the charts of 890 patients with empirically treated or cytologically confirmed PCP, hospitalized during 1987 to 1990 were retrospectively reviewed. Patients were classified by insurance status: self-pay (n = 56), Medicaid (n = 254), or private insurance, including health maintenance organizations and Medicare (n = 580). Primary outcomes were the use and timing of bronchoscopy, the type and timing of PCP therapy, and in-hospital mortality. The results indicate that Medicaid patients were less likely than privately insured patients to undergo bronchoscopy (relative odds = 0.61; 95% CI = 0.40, 0.93; p = 0.02) or to have their diagnosis of PCP confirmed (relative odds = 0.51; 95% CI = 0.33, 0.77), after adjusting for patient, severity of illness, and hospital characteristics. Medicaid patients were approximately three-fourths more likely than privately insured patients (relative odds = 1.73; 95% CI = 1.01, 2.96; p = 0.04) to die in-hospital, after adjusting for patient, severity of illness, and hospital characteristics. However, with further adjustment for confirmation of PCP, Medicaid patients no longer had a significantly higher likelihood of dying in-hospital. We conclude that Medicaid patients are less likely to receive diagnostic bronchoscopy than privately insured or self-insured patients, more likely to be empirically treated for PCP, and more likely to die in-hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1997

Absence of health insurance is associated with decreased life expectancy in patients with cystic fibrosis.

Life expectancy for individuals with cystic fibrosis (CF) has increased dramatically in the last 30 yr, but it is unclear whether the improved survival has applied equally to individuals with different health insurance status. We developed a retrospective inception cohort of all 189 patients with CF born 1/1/55 to 12/31/70 who had at least one hospitalization at a university referral center. The median survival for patients with CF who were without health insurance was 6.1 yr compared with 20.5 yr for those with Medicaid and 20.5 yr for those with private insurance. Using multivariate Cox regression, health insurance and increased socioeconomic status were independently associated with longer survival. The adjusted relative risk of death was greater for the absence of health insurance than for factors previously shown to predict mortality in individuals with CF (female sex and presentation with meconium ileus). In summary, the absence of health insurance was associated with increased mortality rate in children with CF and was a stronger predictor of mortality than variables previously shown to be associated with mortality for CF. If increasing numbers of children with CF lose health insurance coverage, our results suggest that their life expectancy will decrease dramatically.

Adult↗