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PubMed1999

Health care coverage and use of preventive services among the near elderly in the United States.

OBJECTIVES: It has been proposed that individuals aged 55 to 64 years be allowed to buy into Medicare. This group is more likely than younger adults to have marginal health status, to be separating from the workforce, to face high premiums, and to risk financial hardship from major medical illness. The present study examined prevalence of health insurance coverage by demographic characteristics and examined how lack of insurance may affect use of preventive health services. METHODS: Data were obtained from the Behavioral Risk Factor Surveillance System, an ongoing telephone survey of adults conducted by the 50 states and the District of Columbia. RESULTS: Many near-elderly adults least likely to have health care coverage were Black or Hispanic, had less than a high school education and incomes less than $15,000 per year, and were unemployed or self-employed. Health insurance coverage was associated with increased use of clinical preventive services even when sex, race/ethnicity, marital status, and educational level were controlled. CONCLUSIONS: Many near-elderly individuals without insurance will probably not be able to participate in a Medicare buy-in unless it is subsidized in some way.

Educational Status↗

PubMed2002

No care for the caregivers: declining health insurance coverage for health care personnel and their children, 1988-1998.

OBJECTIVES: This study examined trends in health insurance coverage for health care workers and their children between 1988 and 1998. METHODS: We analyzed data from the annual March supplements of the Current Population Survey (CPS), a Census Bureau survey that collects information about health insurance from a nationally representative sample of noninstitutionalized US residents. RESULTS: Of the health care personnel younger than 65 years, 1.36 million (90% confidence interval [CI] = 1.28 million, 1.45 million) were uninsured in 1998, up 83.4% from 1988; the proportion uninsured rose from 8.4% (90% CI = 7.8%, 9.1%) to 12.2% (90% CI = 11.5%, 12.9%). Declining coverage rates in the growing private-sector health care workforce---and declining health employment in the public sector, which provided health insurance benefits to more of its workers---accounted for the increases. Households with a health care worker included 1.12 million (90% CI = 1.05 million, 1.20 million) uninsured children, accounting for 10.1% (90% CI = 9.5%, 10.8%) of all uninsured children in the United States. CONCLUSIONS: Health care personnel are losing health insurance coverage more rapidly than are other workers. Increasingly, the health care sector is consigning its own workers and their children to the ranks of the uninsured.

Adolescent↗

PubMed2006

Centralising drug review to improve coverage decisions: economic lessons from (and for) Canada.

Drug coverage decisions require information about clinically relevant benefits and risks, as well as economic information about direct and indirect costs, in comparison with relevant treatment alternatives. A recent Canadian initiative aims to improve the evidentiary basis for drug coverage decisions through centralised evaluation of the clinical and economic value of new drug products. Centralised review can make important, 'positive' contributions to decision making by raising the evidentiary basis for decisions. Even in the absence of a single-payer for medicines, such information can directly inform decisions focussed on matters of technical efficiency. Centralised review also provides necessary but not sufficient information for the many decisions in this sector that concern allocative efficiency and therefore have 'normative' implications. Thus, in addition to processes for collecting and critically assessing clinical and economic data, effective priority setting requires processes at a local level for engaging affected populations in the consideration of the trade-offs inherent in coverage decisions.

Canada↗

PubMed1999

Trends in health insurance coverage, 1989-1997.

The authors analyze trends in health insurance coverage in the United States from 1989 through 1997, using cross-sectional surveys by the U.S. Census Bureau (Current Population Survey) of 160,000 persons representative of the non-institutionalized population. Between 1989 and 1997, the number of people without health insurance increased by 10.1 million to 43.4 million. From 1989 to 1993, the proportion covered by Medicaid increased by 3.6 percentage points while the proportion covered by private insurance declined by 4.2 percentage points. Since then, private coverage rates have stabilized and Medicaid coverage has decreased. Consequently, the number and percent uninsured continues to rise. Young adults age 18-39 had the largest increase in the proportion uninsured, and rates among children have also risen steeply since 1992. While blacks had the largest increase in the percent uninsured, Hispanics accounted for 35.6 percent of the increase in the number uninsured. Low-income families constituted over half of the increase in the number uninsured, but since 1993 the middle income group had the largest increase in the percent uninsured. Northeastern states had the largest increase in the percent uninsured. Thus, despite economic prosperity, the numbers and rates of the uninsured continue to rise. Principally affected are children and young adults, poor and middle-income families, blacks, and Hispanics.

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↗

PubMed1997

Individual market health insurance reform: portability from group to individual coverage: federal rules for access in the individual market; state alternative mechanisms to federal rules--HHS. Interim final rule with comment period.

This interim final rule with comment period implements section 111 of the Health Insurance Portability and Accountability Act of 1996, which sets forth Federal requirements designed to improve access to the individual health insurance market. Certain "eligible individuals" who lose group health insurance coverage are assured availability of coverage in the individual market, on a guaranteed issues basis, without preexisting condition exclusions. In addition, all individual health insurance coverage must be guaranteed renewable. This rule also sets forth procedures that apply to States that choose to implement a mechanism under State law, as an alternative to the Federal requirements, with respect to guaranteed availability for eligible individuals. It also sets forth the rules that apply if a State does not substantially enforce the statutory requirements.

Career Mobility↗

PubMed1997

Growth hormone coverage policy and implementation: a four-year experience.

Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings.

Child↗

PubMedDate not supplied

Cost-effectiveness and coverage policy.

Cost-effectiveness analyses have become a pervasive element of health care. But they have not had a major impact on medical coverage policy. The challenge of implementing cost-effectiveness as a medical coverage criterion is related to the following issues: (1) Contract language does not include cost-effectiveness as a coverage criterion; (2) cost-effectiveness analyses often take the societal, population-based perspective, while health care is delivered on an individual basis; (3) there is no standard methodology for cost-effective analysis; (4) there is no explicit cut-off between cost-effective and cost-ineffective; and (5) cost-effectiveness analyses are not time sensitive.

Community Health Planning↗

PubMed1999

Disparities in prescription drug insurance coverage.

OBJECTIVES: This article examines socioeconomic differences in supplementary insurance for prescription drugs among Canadians aged 15 or older and how the availability of such insurance affects prescription drug use. DATA SOURCE: The data on prescription drug insurance coverage and drug use are from the cross-sectional Health file of the 1996/97 National Population Health Survey (NPHS) conducted by Statistics Canada. The sample size of the population aged 15 or older was 70,884. ANALYTICAL TECHNIQUES: Rates of insurance coverage for prescription drug services were calculated. All summary estimates were age-adjusted using the 1996/97 population of Canada (both sexes). MAIN RESULTS: Among people aged 15 or older, 61% were covered for prescription medications in 1996/97. Sixty-five percent of workers reported coverage, while those who were not working were less likely to have benefits (52%). Only 38% of lower income groups had insurance compared with 74% of the highest income group. Regardless of the number of chronic diseases individuals had, those with drug insurance were more likely to report taking medication.

Adolescent↗

PubMed2000

Confirming insurance coverage in a telephone survey: evidence from the National Survey of America's families.

Until recently, most surveys of insurance coverage have classified people as uninsured if they have not been assigned some coverage in response to one of a series of questions about specific types of insurance. This "residual" approach to measuring uninsurance rates has not required respondents to either verify their insurance status or confirm that they are uninsured. Using the 1997 National Survey of America's Families, this paper examines the impact of a question confirming whether individuals for whom no insurance coverage is reported are, in fact, uninsured. The results of our analysis suggest that a confirmation question as part of a telephone-based survey works to lower estimates of the uninsured.

Adult↗

PubMed2002

Prescription drug coverage for people with Medicare.

Medicare currently does not provide outpatient prescription drug coverage. People with Medicare who do not have continuous prescription drug coverage face higher out-of-pocket expenditures and may not comply with their prescriptions in order to save money. This brief explores some of the issues facing beneficiaries without drug coverage and describes some of the different options available to help offset the costs of prescription medications.

Aged↗

PubMed2002

Working families' health insurance coverage, 1997-2001.

Despite a booming U.S. economy, falling unemployment and moderate health insurance premium growth, the percentage of working Americans and their families with employer-sponsored health insurance failed to increase substantially between 1997 and 2001, according to findings from the Center for Studying Health System Change (HSC) Community Tracking Study Household Survey. There were, however, dramatic changes in the insurance status of people who lacked access to or did not take up employer coverage: fewer uninsured, more public program enrollment and a decline in coverage by individual insurance and other sources. While the State Children's Health Insurance Program (SCHIP) clearly reduced uninsurance among low-income children, evidence also suggests a fair amount of substitution of public insurance for private coverage.

Adult↗

PubMedDate not supplied

The association between influenza immunization coverage rates and hospitalization for community-acquired pneumonia in Alberta.

BACKGROUND: We compared regional coverage rates of influenza vaccination (composition in 1999/00 was A/Sydney-like A/Beijing-like B/Yamanashi-like and in 2000/01 was A/Moscow A/New Caledonia B/Beijing) to the rates, cost, and mortality for community-acquired pneumonia. METHODS: We used the Pearson's correlation coefficient to establish linear associations between variables derived from Alberta administrative data during the period April 1, 1999 to March 31, 2001. RESULTS: The influenza vaccination coverage rate for the 17 health regions varied between 30% to 80% (mean 70%) in Alberta seniors (n=298,473). The annual hospitalization and ambulatory community-acquired pneumonia attack rates were 2% and 6.5% per year respectively. There were strongly negative correlations between vaccination coverage rates and pneumonia rates requiring hospitalization (r1999=-0.59 and r2000=-0.79 with both p<0.05), total per capita physician and hospital costs for pneumonia (r1999=-0.57 and r2000=-0.79 with both p<0.01), community-diagnosed pneumonia rate (r1999=-0.39, p=0.12 and r2000=-0.70, p<0.01) and per capita in-hospital mortality for pneumonia (r1999=-0.30, p=0.24 and r2000=-0.57, p<0.05). Per capita costs, rates, and mortality were highest and influenza vaccinations rate lowest in the northern, remote health regions. The per capita vaccination cost (about 10 dollars) was small in relationship to the per capita cost of hospital care for pneumonia (about 100 dollars). CONCLUSION: Regional under-utilization of preventive influenza vaccination in Alberta seniors is associated with increased utilization of health services for community-acquired pneumonia.

Aged↗

PubMedDate not supplied

Method for ascertaining denominators for evaluation of population coverage with pneumococcal vaccine.

BACKGROUND: Immunization programs may collect numerator data for the estimation of pneumococcal vaccine coverage, but program evaluators do not have appropriate denominator data for estimation of pneumococcal vaccine coverage, particularly among those eligible for vaccine on the grounds of having chronic health conditions. METHODS: We partitioned the Alberta population into 6 mutually exclusive groups, all but one of which met Canadian recommendations for pneumococcal vaccination. Age-sex specific prevalence rates for each group were estimated using data on chronic health conditions from the Alberta over-sample of the 1996 Household component of the National Population Health Survey, from Alberta Health and Wellness rosters of nursing home residents, and from the Alberta Health Care Insurance Plan Stakeholder Registry. We applied these to Alberta Population Projections to estimate the numbers of persons who should be vaccinated. RESULTS: The proportion of persons recommended for vaccination on the grounds of chronic health condition ranged from 1.5% among those aged less than 12 years to 36% among persons aged 80 years or older. The total number of persons recommended for vaccination at mid-year 2000 is estimated to be 638,561 (21.5% of the Alberta population). INTERPRETATION: This methodology provides denominators for the estimation of pneumococcal vaccine coverage and permits monitoring of local and regional progress towards national goals.

Adolescent↗

PubMed2004

Insurance status and vaccination coverage among US preschool children.

BACKGROUND: Insurance status has been shown to have an impact on children's use of preventive and acute health services. The objective of this study was to determine the relationship between insurance status and vaccination coverage among US preschool children aged 19 to 35 months. METHODS: We linked data from 2 national telephone surveys, the National Immunization Survey and the National Survey of Early Childhood Health, conducted during the first half of 2000. Children were considered up to date (UTD) when they had received at least 4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 MMR vaccine, 3 Haemophilus influenza vaccines, and 3 hepatitis B vaccines at the time the interview was conducted. RESULTS: Among the 735 children in our study sample, 72% were UTD. The vast majority (94%) reported some type of health insurance at the time of the survey. Children with private insurance were more likely to be UTD (80%) than those with public insurance (56%) or no insurance (64%). In a multivariate analysis that controlled for child's race/ethnicity; household income; maternal age/marital status/educational level; location of usual care; and Special Supplemental Nutrition Program for Women, Infants, and Children participation, insurance was no longer an independent predictor of vaccination. CONCLUSIONS: The disparity in vaccination coverage among publicly, privately, and uninsured children is dramatic, underscoring its importance as a marker for underimmunization, despite the multivariate findings. The Vaccines for Children Program, a partnership between public health and vaccination providers who serve uninsured children and those enrolled in Medicaid, is well suited to target and improve vaccination coverage among these vulnerable children.

Child, Preschool↗

PubMed2003

Unmanaged care: towards moral fairness in health care coverage.

Health insurers are generally guided by the principle of "actuarial fairness," according to which they distinguish among various risks on the basis of cost-related factors. Thus, insurers often limit or deny coverage for vision care, hearing aids, mental health care, and even AIDS treatment based on actuarial justifications. Furthermore, approximately forty-two million Americans have no health insurance at all, because most of these individuals cannot afford the cost of insurance. This Article argues that Americans have come to demand more than actuarial fairness from health insurers and are increasingly concerned by what I call "moral fairness." This is evidenced by the hundreds of laws that have been passed to constrain insurers' discretion with respect to particular coverage decisions. Legislative mandates are frequent, but seemingly haphazard, following no systematic methodology. This Article suggests an analytical framework that can be utilized to determine which interventions are appropriate and evaluates a variety of means by which moral fairness could be promoted in the arena of health care coverage.

Actuarial Analysis↗

PubMed2005

Demographics, insurance coverage, and utilization of medical services in newly diagnosed prostate cancer: data from caPSURE.

This study was conducted to identify factors that might influence access to medical services by patients with prostate cancer. The sample comprised 1882 patients who underwent radical prostatectomy and received at least six months of posttreatment follow-up. The investigators found that the type of insurance coverage significantly influenced the number of visits to general practitioners, mental health professionals, and oncologists. However, visits to urologists, nurse practitioners, or alternative-therapy providers were not influenced by type of insurance coverage. Moreover, race, risk profile, and education were significantly correlated with utilization of health services by these patients. The influence of demographic features and insurance coverage on health care utilization by patients with prostate cancer should be further explored.

Aged↗

PubMed2005

Variation in Medicare's local coverage policies: content analysis of local medical review policies.

OBJECTIVE: To assess variation in the content of Medicare's local medical review policies. STUDY DESIGN: Six case studies to compare differences in coverage policies by diagnosis codes, procedure codes, and indications for use. METHODS: All carrier policies from 48 carrier contracts (n = 5213) posted to the Centers for Medicare & Medicaid Services Web site were downloaded on May 31, 2001. All policies in the data set were coded based on a typology: new technology (NT), extensions of new technology (TE), and utilization management (UM) of widely used procedures. We identified policies addressing the same procedure or technology. We required at least 20 separate policies in each case study to allow meaningful comparisons. We randomly selected 1 case study of a diagnostic and 1 for a treatment modality from each policy type (NT, TE, and UM). RESULTS: Given previous research on local carriers, we expected to find variations among policies in each case study. We found substantial similarity, however, among policies covering the NT and TE types. We found significantly more variation among our UM-type case studies. CONCLUSIONS: Medicare legislation has called for greater coverage policy consistency in Medicare. This analysis on variation in policy content, part of a larger study on variation in Medicare's local coverage process, provides data on policy content differences. Policy reform should reflect the nature of and reasons for policy variation as suggested by the findings of this research.

Humans↗