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PubMed1999

Social movements and health insurance: a critical evaluation of voluntary, non-profit insurance schemes with case studies from Ghana and Cameroon.

This paper assesses the performance of voluntary, non-profit health insurance schemes and their potential contribution to health in the two African countries of Ghana and Cameroon. Based on fieldwork conducted in the two countries during the main rainy season (June-July) of 1996, the paper examines whether and in which way the presence or absence of a social movement component might affect the performance of voluntary, non-profit insurance schemes in attaining some key objectives of improving access to health care among the target population, as well as achieving equity, efficiency and financial viability. The paper makes this assessment by examining the performances of each of two case studies according to the criteria of social movement, efficiency, equity, access and financial results. Based on case studies of a community financing insurance scheme in Ghana and a mutual aid insurance association in Cameroon, the study concludes that the evidence is not sufficient to confirm that the presence or absence of such a social movement dynamic per se accounts for the perceived performance of either of the schemes. However, it is also argued that the dynamic of social movement could enhance the design and performance of a scheme, especially the efficiency and quality of health care. Such enhancement is possible provided that the scheme is set up in such a way as to benefit from the specific contribution of a movement component, in particular, if the scheme engages in direct negotiations with providers over the price and quality of care and makes direct payment contracts with such providers. A good scheme design is therefore one of the real keys to success. Moreover, it is arguable that a non-social movement based scheme can incorporate elements of a social movement (such as greater community participation, accountability and autonomy) in the course of time. It is argued that this process would enhance the success of a non-movement-based scheme. The study finally presents some lessons and suggestions from the examination of the schemes which could be of benefit in the design, implementation and evaluation of similar schemes.

Cameroon↗
PubMed1992

Insurability of the adolescent and young adult with heart disease. Report from the Fifth Conference on Insurability, October 3-4, 1991, Columbus, Ohio.

By the mid-1990s there will be more than 500,000 young adults in the United States over the age of 21 with a cardiac malformation. Presently more than half of this population is denied insurance coverage entirely or in part because of their preexisting condition. Because some did not have coverage and because of uncertainty about whom to see for their cardiology care, patients assessed in NHS-II who were evaluated by their physician on an annual basis before the age of 21 were seen by a cardiologist only every 10 years after the age of 21. However, they have been shown by NHS-II to be well-educated, productive in the workplace, and to share an equal place in society with the general population. Their health-care costs are decidedly lower after the age of 21 than before. This group represents a microcosm of a general society of more than 37 million Americans who, for various reasons, are not insured. Dr. Wiener described an American health-care system in crisis. Smaller companies are no longer able to afford health insurance for all their employees, especially for those with preexisting conditions, because of an industry pricing concept based on a claims-experience standard rather than a community standard. The insurance industry, the government, and patients are demanding medical cost-containment. Health-care costs, 12.2% of the gross national product in 1990, are climbing, and no end to this increase is presently in sight.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2002

Millions of mothers lack health insurance coverage in the United States. Most uninsured mothers lack access both to employer-based coverage and to publicly subsidized health insurance.

Some 5.9 million American mothers caring for young or school-aged children lack health insurance. Although nearly nine in ten uninsured mothers are members of working families, most lack access to affordable coverage through their job or a spouse's job. Most are ineligible for publicly subsidized coverage unless their incomes are far below the poverty line. The millions of uninsured mothers are at high risk of going without needed preventive and primary care. If they become seriously ill, their families can face the prospect of a financial crisis. The nation has made significant progress in extending health care coverage to children in low-income families through Medicaid and the State Children's Health Insurance Program (SCHIP), but no comparable effort has been made to insure the mothers of these children. A few states have started to address the problem by transforming their SCHIPs into family-based programs that also cover low-income parents. Bipartisan legislation under consideration, known as FamilyCare, would encourage this trend by providing more federal funding to states that could be used to extend health insurance to the parents of children already covered by publicly funded programs.

Adult↗
PubMed1994

[Illness and social insurance in Spain during the early Francoist regime (1936-1951). The ill-fated Compulsory Tuberculosis Insurance program].

The campaign against tuberculosis was one of the main health tasks undertaken by the Francoist regime from the beginning of the Civil War. At the same time, the project to introduce compulsory insurance against tuberculosis was initiated, based on the Italian model of social insurance. This article analyzes the circumstances that impeded the implementation of the insurance program. One determining factor was the division of power among the different factions of the Francoist regime, which led to the introduction of compulsory health insurance by the Falangist Party. Relevant features concerning the organization and goals of the anti-tuberculosis campaign in Spain from 1936 to 1951 are also described.

Communicable Disease Control↗
PubMedDate not supplied

Methods for estimating the labour force insured by the Ontario Workplace Safety and Insurance Board: 1990-2000.

This paper presents a methodology for estimating the size and composition of the Ontario labour force eligible for coverage under the Ontario Workplace Safety & Insurance Act (WSIA). Using customized tabulations from Statistics Canada's Labour Force Survey (LFS), we made adjustments for self-employment, unemployment, part-time employment and employment in specific industrial sectors excluded from insurance coverage under the WSIA. Each adjustment to the LFS reduced the estimates of the insured labour force relative to the total Ontario labour force. These estimates were then developed for major occupational and industrial groups stratified by gender. Additional estimates created to test assumptions used in the methodology produced similar results. The methods described in this paper advance those previously used to estimate the insured labour force, providing researchers with a useful tool to describe trends in the rate of injury across differing occupational, industrial and gender groups in Ontario.

Absenteeism↗
PubMed2005

[Role of obligatory medical insurance in insuring victims of occupational accidents and patients with occupational diseases].

The author described current system insuring victims of occupational accidents and patients with occupational diseases, with participation of all off-budget funds and health service budget, with consideration of work conditions and occupational morbidity in Rostov region. Analysis covered experience and efficiency of Obligatory Medical Insurance System (unique in this country, which participated in insuring occupational victims) in insuring victims of occupational accidents in the region.

Accidents, Occupational↗
PubMed1982

[Fractures of the thoracolumbar spine. A follow-up of insured and not insured (author's transl)].

Out of a number of patients treated between 1966 to 1977 for fractures of the thoracal and lumbar spine (according to Ehlert) 73 cases were followed up. 38 patients of these were insured, 37 were not. There were equal clinical results for both groups. The complaints of insured patients, however, were four time higher, with their out of work time being double as high as that of patients without insurance. If, therefore, complaints of insured patients cannot be evaluated with absolute objectivity, they should be considered with caution.

Disability Evaluation↗
PubMedDate not supplied

How are net health insurance benefits distributed in the employment-related insurance market?

The recent health care reform debate has questioned whether the health insurance market effectively pools risks and transfers income across states of health. We use data from the 1987 National Medical Expenditure Survey to examine how net health insurance benefits are distributed in the employment-related insurance market. We find this market to transfer income from those in good health to those with health problems and the tax subsidy from employer health insurance contributions to be a crucial determinant of the net benefit distribution. To the extent society views these transfers as meritorious, our findings suggest caution regarding initiatives to limit or eliminate the tax subsidy.

Actuarial Analysis↗
PubMed2003

Pitching plans to the uninsured. Insurers increasingly see viable market in growing pool of middle-class workers who don't have health insurance.

It's a bold new world in healthcare insurance. A few years ago, insurers would have been reluctant to use advertising dollars to reach the uninsured. But now, as the average income of the typical uninsured person is climbing and Congress is pondering initiatives to expand coverage, the market is gaining zealous suitors. "Things are really heating up," says Merrill Matthews Jr., left, director of the Council for Affordable Health Insurance.

Advertising↗
PubMed1990

Multiple choice health insurance: the lessons and challenge to private insurers.

A health policy consultant with 20 years of experience in public and private health insurance, and particularly multiple choice systems, suggests the evidence is in on our national effort to contain costs through competition, HMOs, and multiple choice health plans. Specifically, we have learned that 1) multiple choice plans are not containing costs for employers, 2) while group and staff model HMOs contain costs, few have cut employers' costs in multiple choice health plans, and 3) group and staff model HMOs' capacity to contain costs has not been matched by insurers' managed care plans. Three options for insurers and HMOs to offer employers are outlined. The options are aimed at changing the behavior of providers so they offer lower cost health care.

Community Participation↗
PubMed1996

[Prevalence and distribution of stroke and transient ischemic insults: secondary data analysis of a representative sample of insured members of the General Local Insurance Dortmund].

Apoplexia is not only one of the leading causes of death, but also a major contributor to disability in the aged. Population based prevalence rates, though being of basic importance for describing and planning health care structures, are sparse in the Federal Republic of Germany. We estimated the prevalence of apoplexia and transient ischemic attack (TIA). Data were gathered from a 5% representative random sample of insured of the local statuatory health insurance (AOK) in Dortmund, Germany (n = 7447). Cases were identified by the diagnosis on medical certificates, being further validated internally by other patient data. The rough prevalence rate was 0.86% (m 0.79%, f 0.93%) for apoplexia and 0.6% (m 0.4%, f 0.78%) for TIA. Adjusted for age and sex to the whole population of the FRG (excluding the former German Democratic Republic) the prevalence rate was 0.75% (m 0.8%, f 0.7%) for apoplexia and 0.52% (m 0.41%, f 0.63%) for TIA. 65% of the insured with apoplexia were 70 years and older; their average age was 71.7 years. The average age of the insured with TIA was 65.4 years. Prevalence rates for apoplexia increased continuously by age and were higher for men than for women in all age groups. Prevalence rates for TIA also increased with age, but under men only to the age of 70; after that-simultaneous to a steep rise of apoplexia prevalence-no more TIAs were noticed.

Adult↗
PubMed2005

Who really pays for health insurance? The incidence of employer-provided health insurance with sticky nominal wages.

This paper addresses two seeming paradoxes in the realm of employer-provided health insurance: First, businesses consistently claim that they bear the burden of the insurance they provide for employees, despite theory and empirical evidence indicating that workers bear the full incidence. Second, benefit generosity and the percentage of premiums paid by employers have decreased in recent decades, despite the preferential tax treatment of employer-paid benefits relative to wages-trends unexplained by the standard incidence model. This paper offers a revised incidence model based on nominal wage rigidity, in an attempt to explain these paradoxes. The model predicts that when the nominal wage constraint binds, some of the burden of increasing insurance premiums will fall on firms, particularly small companies with low-wage employees. In response, firms will reduce employment, decrease benefit generosity, and require larger employee premium contributions. Using Current Population Survey data from 2000-2001, I find evidence for this kind of wage rigidity and its associated impact on the employment and premium contributions of low-wage insured workers during a period of rapid premium growth.

Adult↗
PubMed2004

Subsidies to employee health insurance premiums and the health insurance market.

One approach to covering the uninsured that is frequently advocated by policy-makers is subsidizing the employee portion of employer-provided health insurance premiums. But, since the vast majority of those offered employer-provided health insurance already take it up, such an approach is only appealing if there is a very high takeup elasticity among those who are offered and uninsured. Moreover, if plan choice decisions are price elastic, then such subsidies can at the same time increase health care costs by inducing selection of more expensive plans. We study an excellent example of such subsidies: the introduction of pre-tax premiums for postal employees in 1994, and then for the remaining federal employees in 2000. We do so using a census of personnel records for all federal employees from 1991 through 2002. We find that there is a very small elasticity of insurance takeup with respect to its after-tax price, and a modest elasticity of plan choice. Our results suggest that the federal government did little to improve insurance coverage, but much to increase health care expenditures, through this policy change.

Employer Health Costs↗
PubMed2002

Managing the behavior of the medically insured in Germany: the acceptance of cost-sharing and risk premiums by members of the statutory health insurance.

In the course of the conflicts over the reform of statutory health insurance in Germany complaints about moral hazard-behavior on the part of the insured were repeatedly raised and linked to the demand for expanding managerial incentives aimed at reducing the consumption of health care benefits (copayments). However, critics and supporters of managerial incentives mostly neglect the perceptions and dispositions of the insured. In contrast, the article examines how members of the statutory health insurance scheme assess managerial intervention, namely cost-sharing and risk premiums.

Cost Sharing↗
PubMedDate not supplied

On being new to an insurance plan: health care use associated with the first years in a health insurance plan.

BACKGROUND: We wanted to compare health care utilization and costs in the first year of being in a health insurance plan with those of subsequent years. METHODS: We used claims data from an independent practitioner association (IPA)-style managed care organization in the Rochester, NY, metropolitan area from 1996 through 1999. Cross-sectional and panel analyses of up to 4 years of claims data were conducted, involving 335,547 adult patients assigned to the panels of 687 primary care physicians (internists and family physicians). Multivariate analyses, adjusting for age, sex, case mix, and socioeconomic status derived from ZIP codes, examined the relationship between the first year of health insurance and Papanicolaou tests, mammograms in women older than 40 years, physician use, avoidable hospitalization, and expenditures. RESULTS: After multivariate adjustment, the first year of insurance was associated with a higher risk of not getting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician, and higher expenditures, especially for testing. There was no relationship, however, between Papanicolaou test compliance and year of enrollment. CONCLUSIONS: The findings suggest there might be adverse clinical and financial implications associated with changing insurance.

Adult↗
PubMed2006

Insuring children or insuring families: do parental and sibling coverage lead to improved retention of children in Medicaid and CHIP?

Recent research indicates that 3 million children leave Medicaid or the Children's Health Insurance Program (CHIP) each year and become uninsured, despite continuing eligibility. This paper explores the effect of family coverage on drop-out among children in these two programs, using instrumental variables to address the endogeneity of parental and sibling coverage in Medicaid/CHIP. Using the Current Population Survey March Supplement (1999-2004), I find that having a parent (primarily a mother) or sibling in public insurance is associated with a significantly lower risk of drop-out; after instrumenting with parental and sibling eligibility, only parental coverage remains a significant predictor of retention. I conclude that policy attempts to expand health insurance to the 8.5 million uninsured children in the U.S. would be much more effective if they covered parents and children in the same program.

Adolescent↗
PubMed2005

Barriers to accessing benefits in a community-based insurance scheme: lessons learnt from SEWA Insurance, Gujarat.

This paper seeks to examine barriers faced by members of a community-based insurance (CBI) scheme, which is targeted at poor women and their families, in accessing scheme benefits. CBI schemes have been developed and promoted as mechanisms to offer protection to poor families from the risks of ill-health, death and loss of assets. However, having voluntarily enrolled in a CBI scheme, poor households may find it difficult or impossible to access scheme benefits. The paper describes the results of qualitative research carried out to assess the barriers faced in accessing scheme benefits by members of the CBI scheme run by the Self-Employed Women's Association (SEWA) in Gujarat, India. The study finds that the members face a variety of different barriers, particularly in seeking hospitalization and in submitting insurance claims. Some of the barriers are rooted in factors outside the scheme's control, such as illiteracy and financial poverty amongst members, and inadequacies of the transportation and health care infrastructure. But other barriers relate to the scheme's design and management, for example, lack of clarity among scheme staff regarding the scheme's rules and processes, and requirements that claimants submit documents to prove the validity of their claims. The paper makes recommendations as to how SEWA Insurance can address some of the identified barriers and discusses the relevance of these findings to other CBI schemes in India and elsewhere.

Community Networks↗
PubMed2005

Gatekeepers in sickness insurance: a systematic review of the literature on practices of social insurance officers.

Decisions concerning entitlement to sickness benefits have a substantial impact on the lives of individuals and on society. In most countries, such decisions are made by staff of private or public insurance organisations. The work performed by these professionals is debated, hence more knowledge is needed on this subject. The aim of the present study was to review scientific studies of the practices of social insurance officers (SIOs) published in English, Danish, Norwegian and Swedish. Studies were searched for in literature databases, in reference lists, and through personal contacts. Analyses were made of type of study, areas investigated, research questions, theories used, and the results. Sixteen studies were included. SIOs and several other actors are responsible for applying measures to minimise sick-leave and promote return to work (RTW). The studies focusing on coordination of such measures revealed that SIOs felt unsure about how to handle their contacts with clients and other actors. One study indicated that the SIOs, partly due to lack of time, accepted the recommendations of physicians instead of making their own judgments about granting sickness benefits. While all SIOs must make decisions concerning entitlement to sickness benefits on a daily basis, few of the reviewed studies scrutinised the actual granting of sickness compensation. The studies were also deficient in that they investigated the decision latitude of the SIOs from a very limited perspective, mainly on an individual level and often primarily in relation to colleagues and/or clients rather than to the laws and regulations of the sickness insurance. The concepts and framework in this area of research need to be developed to facilitate elucidation of the interaction between different actors in local spheres, professionals in different disciplines, and between welfare staff and individual citizens.

Certification↗