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PubMed1985

Liability of the mentally ill and their insurers in negligence and other civil actions.

Although familiar with the insanity defense, psychiatrists know little about the liability of mentally ill persons in civil actions or the secondary liability of their insurers. Generally the mentally ill are responsible civilly for their actions regardless of mental state except where the law requires specific intent and the illness negates such intent. Psychiatrists and other mental health workers may thus have grounds for suit against patients who injure them. While insurance coverage may exclude intentional acts, insurers may be civilly liable, even for blatant criminal acts. The author reviews the relevant laws and presents illustrative case examples.

Criminal Law↗
PubMed2000

Access to health care for children with special health care needs.

OBJECTIVE: To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs. METHODS: We analyzed data on 57 553 children younger than 18 years old included in the 1994-1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services. RESULTS: Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994-1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87. 6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6. 1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14. 9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost. CONCLUSIONS: This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed.

Adolescent↗
PubMed1985

SIPP and health care issues.

There are three major areas in health care policy which can be addressed by the data elements in the Survey of Income and Program Participation (SIPP): (1) health insurance coverage and the stability of insurance over time; (2) health disability and its relationship to socioeconomic variables, including unemployment, over time; and (3) health care utilization. The survey does not, however, include information on health care expenditures or on details of visits to providers.

Persons with Disabilities↗
PubMed1976

Surgical rates in the Canadian provinces, 1968 to 1972.

Canadian and provincial rates for eight elective and seven nonelective operations were determined from 1968 through 1972. Of the elective procedures considered, the Canadian tonsillectomy rate decreased substantially and rates for hysterectomy and cholecystectomy showed large increases. The provinces reflected national trends for these three operations. Except for coletomy, which increased 36%, rates for the nonelective procedures showed little change. Correlations between the numbers of surgical personnel and the elective surgery rates in the provinces were demonstrated in 3 of the 5 years; these are best shown at the extremes. Newfoundland had the fewest surgeons, a bed: population ratio below the national average and the lowest combined elective surgical rate; Alberta ranked high in all three categories. In the seven other provinces, there was less variation in the number of surgeons, hospital beds and elective surgical rates. Provinces with extensive insurance coverage prior to universal medical insurance reduced their combined elective surgery rate, while provinces where fewer people were insured showed increases. In the absence of different methods of payment for surgical services and marginal changes in the number of hospital beds and the number of surgeons, more insured persons produced more elective surgery.

Canada↗
PubMed1986

Reflections of a CHAMPUS-APA peer reviewer.

Peer review is a major professional response to the problems of health insurance coverage for psychiatric services. Standard insurance programs reimburse only services that are conventional and cost-effective. The system assumes that services are skillfully documented by providers. Experience as a peer reviewer helps clinicians acquire skill in documentation.

Cost-Benefit Analysis↗
PubMedDate not supplied

Whence and whither health insurance? A revisionist history.

Throughout the postwar era in federal health policy, policymakers have sought to expand both public and private insurance coverage, while wrestling with the cost consequences of the demand generated by the insurance-financing mechanisms thus created. This essay advances the view that the limits to insurance expansion have been reached and that public and private plan sponsors will henceforth continually "thin out" the coverage they offer. In this environment, policymakers seeking to mitigate access concerns may need to consider strategies that promote direct service delivery. This emerging regime, it is argued, will have important implications for the future of innovation in health care.

Delivery of Health Care↗
PubMed2000

To buy, or not to buy: factors associated with the purchase of nongroup, private health insurance.

BACKGROUND: Employment-based health insurance coverage is declining in the United States. Many recent efforts to increase coverage have promoted the individual purchase of insurance, with or without subsidies. OBJECTIVES: To study the associations of factors including minority group membership, education, income, wealth, and health status with the voluntary purchase of nongroup, private health insurance. DESIGN: Analysis of the 1987 National Medical Expenditure Survey (NMES). SUBJECTS: Adult respondents to the NMES who were younger than 65 years of age in 2,574 health-insurance eligibility units (HIEUs) and who either were uninsured or who purchased nongroup, private health insurance for all of 1987. MEASURES: Adjusted odds ratios and marginal effects for the associations of minority group membership, educational attainment, income, and wealth with the purchase of nongroup insurance. RESULTS: Lower-income and less-wealthy HIEUs were much less likely to purchase insurance than higher-income and wealthier HIEUs, with income and wealth measures having relatively independent effects. With simultaneous adjustment for income, wealth, and other factors, members of minority groups had less than half the odds of non-Hispanic whites and persons with less than a high school education had less than half the odds of college graduates of purchasing nongroup insurance. CONCLUSIONS: Minorities and the less educated are much less likely to buy their own health insurance, even after adjustment for income and wealth. Programs encouraging the voluntary purchase of health insurance are likely to widen coverage gaps between historically disadvantaged groups and others.

Adult↗
PubMed2004

Health coverage instability for mothers in working families.

Using data from the National Longitudinal Survey of Youth, the authors examined the health insurance coverage stability of 1,667 women in working families over a three-year period (1995-1997). Findings revealed that coverage instability is common. Nearly one-half of low-income women experienced health coverage instability over the three-year study period, and low-income women with poor education, single marital status, low work hours, and frequent job changes were at even greater risk of coverage instability. The findings also imply that women affected by recent welfare reforms are likely to experience widespread health coverage problems. The implications for health care policy development, social work administration, and social work practice are discussed.

Demography↗
PubMed1977

Private health insurance in 1975: coverage, enrollment, and financial experience.

More improvement in the scope than in the quality of private health insurance coverage took place during 1975. Four-fifths of the population under age 65 was covered for hospital and surgical care, and nearly that proportion was protected against the costs of physicians' in-hospital visits, X-ray and laboratory examinations, and prescribed out-of-hospital drugs. The $33.6 billion in premiums paid by consumers resulted in the return of only $28.9 billion in benefits, which covered just 44% of their total personal health care expenditures. Major-medical insurance, held by an estimated 43% of the population, helped to overcome some of the deficiencies of private insurance--dollar limitations on health care services, ceilings on the duration of hospital stays, and exclusions for some types of care. It also provided economic protection against catastrophic expenses. Premiums and subscription income rose faster than benefits as private insurers attempted to keep their coverage in line with rising health care costs. The overall underwriting gain was due largely to a $952.4 million gain in group business by the insurance companies.

Adult↗
PubMed2006

Health care access and utilization among women who have sex with women: sexual behavior and identity.

Past research has shown that women who either have sex with women or who identify as lesbian access less preventive health care than other women. However, previous studies have generally relied on convenience samples and have not examined the multiple associations of sexual identity, behavior and health care access/utilization. Unlike other studies, we used a multi-lingual population-based survey in New York City to examine the use of Pap tests and mammograms, as well as health care coverage and the use of primary care providers, among women who have sex with women and by sexual identity status. We found that women who had sex with women (WSW) were less likely to have had a Pap test in the past 3 years (66 vs. 80%, p<0.0001) or a mammogram in the past 2 years (53 vs. 73%, p=0.0009) than other women. After adjusting for health insurance coverage and other factors, WSW were ten times [adjusted odds ratio (AOR), 9.8, 95% confidence interval (CI), 4.2, 22.9] and four times (AOR, 4.0, 95% CI 1.3, 12.0) more likely than non-WSW to not have received a timely Pap test or mammogram, respectively. Women whose behavior and identity were concordant were more likely to access Pap tests and mammograms than those whose behavior and identity were discordant. For example, WSW who identified as lesbians were more likely to have received timely Pap tests (97 vs. 48%, p<0.0001) and mammograms (86 vs. 42%, p=0.0007) than those who identified as heterosexual. Given the current screening recommendations for Pap tests and mammograms, provider counseling and public health messages should be inclusive of women who have sex with women, including those who have sex with women but identify as heterosexual.

Adolescent↗
PubMed1997

Socioeconomic and racial/ethnic factors affecting non-fatal medically attended injury rates in US children.

OBJECTIVE: Using a representative survey of US children, the purpose was to evaluate separate effects of socioeconomic and racial/ethnic factors, including access to care, on medically attended non-fatal injury rates. METHODS: Multivariate linear regression models were used to determine associations between injuries and health care coverage (insurance or Medicaid), having a place to go for care, race/ethnicity, maternal education, number of adults and children in the household, poverty, and urbanicity. The 1988 Child Health Supplement to the National Health Interview Survey included questions on medically attended injuries, and their cause, location, and effects on the child. Injury categories included total, consequential, occurrence at home or school, falls, and being struck or cut. RESULTS: Lack of health care coverage was consistently associated with lower medically attended injury rates in non-Hispanic blacks or whites and Mexican-Americans, but affected total rates for each group differently due to unequal distribution of health care coverage. Injuries occurred about 40% more frequently to children and adolescents living in single adult households compared with two adult homes for all injury categories except for injuries occurring at school. CONCLUSIONS: Preventive interventions targeted to specific populations based on assumptions that poverty, lack of education, or minority status result in greater risks for injuries require a closer look. Efficient targeting should address underlying factors such as differences in exposures and environments associated with single adult homes or recreational activities. Data sources used to target high risk populations for interventions need to address bias due to access to care.

Adult↗
PubMedDate not supplied

Medicare beneficiaries and drug coverage.

Whether or not to add a prescription drug benefit to the basic Medicare package is at the forefront of congressional debate. Using data from the 1996 Medicare Current Beneficiary Survey (MCBS), we examine changes in drug insurance coverage levels from 1995 to 1996 and compare drug use and spending data for Medicare beneficiaries with and without drug coverage. The data show the enrollees without drug insurance consistently use fewer prescriptions, spend more out of pocket, and have less in total drug expenditures than their insured peers.

Adult↗
PubMed1997

Health insurance and the financial impact of IDDM in families with a child with IDDM.

OBJECTIVE: To examine the health insurance experience and out-of-pocket health care costs of families with a child with IDDM. RESEARCH DESIGN AND METHODS: A case-control study of 197 families with a child with IDDM and 142 control families with no diabetic children was conducted. IDDM-affected families were identified from the Allegheny County IDDM Registry. Brothers and sisters of the parents in the IDDM-affected families were asked to participate as control subjects. Health insurance coverage and the money that families spent on health care services and supplies not reimbursed by insurance (out-of-pocket costs) were assessed by questionnaire. RESULTS: No difference was found between the IDDM-affected and control families in the percentages with or without insurance. Families with low household incomes ($10,000-$19,999) were at the greatest risk for having no insurance. While coverage provided by private plans was similar between the IDDM-affected and control families, many families had no reimbursement for insulin (10%), syringes (10%), or blood testing strips (30%). Out-of-pocket expenses were 56% higher in the IDDM-affected families than in the control families. Seventeen percent of the IDDM-affected families had expenses over 10% of their household income. This particularly affected families with low household incomes. Pre-existing illness clauses and insurance denial affected only a small proportion of the case families. CONCLUSIONS: These data illustrate that most families with a child with IDDM have health insurance, yet still incur larger out-of-pocket health care costs than do families without the presence of diabetes. IDDM-affected families likely face a number of economic decisions regarding health insurance and the use of health care.

Adolescent↗
PubMed1991

Determinants of health insurance status among young adults.

This study evaluates the determinants of insurance coverage in the 18-24-year-old population using the National Medical Care Utilization and Expenditure Survey. Three specific issues are addressed: 1) the characteristics of the insured versus uninsured, 2) the reason given by the uninsured for not having coverage, and 3) the role of employment status and other variables in determining insurance status. An important consideration is whether age or usual activity is more important in its effect on insurance status. The results show that employment is the strongest predictor of insurance status in all age and usual activity subgroups. Generally, permanent/full-time workers are most likely to be insured. An exception to this trend is found for those attending school who are also permanent/part-time workers. These individuals are more likely to be insured than permanent full-time workers who are in school. Furthermore, young adults with lower incomes, less education, rural residence, not married, hispanic ethnicity, and Western geography are the least likely to be insured. The findings of this analysis can be used by policymakers to identify the mechanisms that can best enhance insurance coverage among young adults.

Adult↗
PubMed1998

Next steps in incremental health insurance expansions: who is most deserving?

President Clinton's proposal to allow near-elderly individuals--those between the ages of 55 and 64--to buy-in to Medicare is the latest initiative to expand health insurance coverage incrementally by targeting particular age groups. Health insurance expansions for children were passed last year, and assistance to young adults--those age 19 to 24--has also been discussed. The rationale for targeting individuals in these age groups is that they are presumed to be vulnerable. However, vulnerability to uninsurance includes not only the risk of being uninsured, but also the potential health and financial consequences that result from not having coverage, each of which varies substantially across age groups. This Issue Brief examines the vulnerability of the near-elderly and young adults with respect to uninsurance.

Adult↗
PubMed2005

Being uninsured: impact on children's healthcare and health.

PURPOSE OF REVIEW: There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children. RECENT FINDINGS: With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs. SUMMARY: Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.

Child↗
PubMed2005

Health insurance disparities in traditional and contingent/alternative employment.

Relative to whites, Hispanics and blacks are less likely to have employer health insurance coverage. We examine whether ethnicity or race affects employment in traditional jobs or in contingent and alternative work arrangements, and whether ethnicity or race affects insurance offer, eligibility, and/or enrollment, conditional on employment sector. Health insurance disparities relative to whites are more pronounced for Hispanics, primarily due to disparities in employment by firms that offer coverage. Eliminating racial/ethnic disparities in offers, eligibility, and takeup would increase insurance coverage rates of Hispanics in traditional jobs and of both Hispanics and blacks in contingent and alternative jobs.

Adult↗
PubMed1998

The association between health care coverage and the use of cancer screening tests. Results from the 1992 National Health Interview Survey.

OBJECTIVES: The authors investigated whether utilization of six different cancer screening tests (mammography, clinical breast exam, Pap smear, Fecal Occult Blood Test, and Digital rectal exam) varied according to type of health care coverage. METHODS: Data on the use of cancer screening tests and coverage in two age groups from a 1992 nationally representative cross-sectional survey of approximately 9,400 adults were analyzed. Multiple logistic regression analysis was used to estimate proportions of persons screened according to type and extent of coverage, adjusted for socioeconomic, demographic, and health status characteristics. RESULTS: Persons aged 40 to 64 years with Medicaid coverage were equally as likely to receive five of six cancer screening tests as those with private fee-for-service coverage, and both groups were much more likely to be screened (70% higher for all six tests) than those who had no coverage. In contrast, persons aged 65 years and older who had supplemental private fee-for-service insurance in addition to Medicare were more likely to receive five of six tests than those with Medicare and Medicaid or those with Medicare only. For all six screening tests, managed care enrollees at all ages were approximately 10% more likely to be screened than persons enrolled in private fee-for-service plans. Fecal Occult Blood Test (25% versus 20%) and digital rectal exams (44% versus 38%) in persons aged 40 to 64 years and mammography (59% versus 48%) and Fecal Occult Blood Test screening (38% versus 30%) in the elderly were significantly more frequent for persons in managed care plans. CONCLUSIONS: The extent of fee-for-service insurance coverage in the traditional indemnity US health care system was positively associated with the use of cancer screening tests. The authors found less difference in use of cancer screening between managed care and fee-for-service care in 1992 than we expected based on earlier research comparing use of preventive services in health maintenance organizations with fee-for-service care.

Adolescent↗