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PubMed2002

[So-called trauma criterium (a criterium of DSM-IV) in posttraumatic stress disorder and its significance for social and legal insurance (I)].

Since the diagnosis posttraumatic stress disorder (PTSD) was included in the American diagnosis system DSM-III in 1980, the ongoing scientific discussion has led to a shift in the definition of the so called A-criterion (trauma criterion) away from the general theory that the disease-causing event has to be outside normal human experience towards the point of view that it is more or less determined by the subjective experience of the individual. Without wishing to become involved in the discussion, in the publication the author tries to explain, on the basis of references to basic concepts found in insurance law (accident, initial damage, suitability of event, objectivity, epidemiological considerations), that in social insurance as well as in non-life insurance an objective insured event which has a severe emotional impact on the individual is a prerequisite for payment. The conclusions is that not every mental disorder which occurs after an insured event and which has quite rightly been classified as PTSD (or partial PTSD) on the basis of the symptoms involved in accordance with ICD-10/DSM-IV (criteria B-D) necessarily results in payment under insurance law.

Diagnostic and Statistical Manual of Mental Disord↗
PubMed2004

"Any Willing Provider" laws not preempted by Employee Retirement Income Security Act (ERISA). Kentucky Association of Health Plans, Inc. et. al. v. Miller, Commissioner, Kentucky Department of Insurance.

"Any Willing Provider" laws are not preempted by ERISA because they are state laws regulating insurance if they are (1) specifically directed toward entities engaged in insurance and (2) substantially affect the risk-pooling arrangement between the insurer and the insured. Thus, a state may prohibit health maintenance organizations (HMOs) from creating exclusive "provider networks" of doctors, hospitals and other health care providers by excluding other providers who are "willing and able" to comply with all the HMO's contractual terms if the law meets the new two-prong test established by the Supreme Court in this case. The Court made a "clean break" from using the McCarran-Ferguson Act factors for determining whether certain practices constitute "the business of insurance," when deciding when they regulate insurance for purposes of ERISA preemption.

Employee Retirement Income Security Act↗
PubMed2005

Labor market, financial, insurance and disability outcomes among near elderly Americans with depression and pain.

BACKGROUND: The economic burden of depression has been documented, but the role of comorbid conditions is unclear. Depression and comorbid pain are particularly common, are associated with worse clinical outcomes and require different care than "pure'' depression. Does this comorbidity account for a large share of the adverse social outcomes attributed to depression? AIMS OF STUDY: We analyzed the relationship between depression and comorbid pain, and labor market, financial, insurance and disability outcomes among Americans aged 55-65. METHODS: Cross-sectional data were used from Wave 3 of the Health and Retirement Survey, a nationally representative sample of individuals aged 55-65 surveyed in 1996. Multivariate regression analyses, controlling for socio-demographics and chronic health conditions, estimated the associations between depression and pain, and economic outcomes. Outcomes included: employment and retirement status, household income, total medical expenditures, government health insurance, social security, limitations in activities of daily living (ADLs), and health limitations affecting work. Primary explanatory variables included the presence of severe pain, mild/moderate pain, or absence of pain, with or without depression. RESULTS: Compared to depression alone, depression and comorbid pain was associated with worse labor market (non-employment, retirement), financial (total medical expenditures), insurance (government insurance, social security) and disability outcomes (limitations in ADLs, health limitations affecting work), after covariate adjustment (p <or= 0.01, except retirement with p < 0.1). Findings were even more disparate as level of pain severity increased. The simulated results showed that the magnitudes of the adverse effects were attributed disproportionally to individuals with comorbid pain and depression versus "pure'' depression. Of those with depression, 51% had comorbid pain. Yet, this subgroup of depressed individuals accounted for 59% of those not employed, 61% of those with government health insurance, 79% of those with limitations in ADLs, and 72% of those with health limitations affecting work. DISCUSSION AND LIMITATION: Depression with comorbid pain, not depression alone was responsible for a large part of the higher economic burden associated with depression. The study is limited by self-reported measures of pain, depression, and outcomes. It is cross-sectional and cannot identify causal effects of depression with pain. These findings may not be generalizable to other age groups. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The depressed with comorbid pain appear to experience greater burden through increased costs and worse functioning and may require different management than those with depression alone. The depressed with comorbid pain may benefit from treatment practices and guidelines that address the duality of these conditions throughout the process of care. IMPLICATION FOR HEALTH POLICIES: The depressed with comorbid pain were more likely to receive government support than depression alone. Given the central role of employer-sponsored health insurance in the U.S., they may have worse access to health care because they leave employment or retire earlier. With the evolving state of Medicare, broad formulary access to mental health treatments might be considered. IMPLICATIONS FOR FURTHER RESEARCH: Further research should focus on causality of depression and comorbid pain on economic outcomes. Depression research should consider the heterogeneity of this disorder in outcomes assessment.

Aged↗
PubMed1991

The effectiveness of consumer choice in the Medicare supplemental health insurance market.

This article examines the factors that affect Medicare beneficiaries' choices in the supplemental health insurance market. Data include detailed survey information as well as copies of the health insurance policies owned by a sample of approximately 2,500 Medicare beneficiaries in six states during 1982. Logit analysis is employed to analyze the determinants of four dependent variables: whether a person owns (1) one or more private supplemental insurance policies, (2) two or more policies, (3) at least one policy that we define as "effective," and (4) a policy we define to be "less effective." Those who are better off from a socioeconomic standpoint appear to be making more effective choices in the supplemental health insurance market. However, there does not appear to be a relationship between consumer ignorance or vulnerability and the purchase of multiple supplemental insurance policies. Study results imply an important role for public policy in helping to provide the information necessary to ensure that the most vulnerable beneficiaries make insurance choices that are in their best interest.

Aged↗
PubMed1993

Can an employer-based health insurance system be just?

It is America's distinctive practice to tie private health insurance to employment, and recent proposals have tried to retain this link through mandating that all employers provide health insurance to their employees. My primary approach to these issues is neither economic, nor historical, nor political but ethical. After a brief historical overview, I outline a general approach to evaluating the ethical significance of linking the distributions of distinct goods. I examine whether an unjust distribution of jobs spoils justice in the distribution of health insurance, taking as a central example gender inequities in employment and exploring their impact on job-based health insurance. Second, I explore the possibility that justly awarding jobs guarantees justice in employment-sponsored insurance. However, linking the distributions of different goods remains problematic, because such links inevitably undermine equality by enabling the same individuals to enjoy advantages in many different distributive areas. Finally, I examine recent proposals to reform America's health care system by requiring all employers to provide health insurance to their employees. I argue that such proposals lend themselves to the same ethical problems that the current system does and urge greater attention to alternative reform options.

Employer Health Costs↗
PubMed2001

Supplemental insurance and use of effective cardiovascular drugs among elderly medicare beneficiaries with coronary heart disease.

CONTEXT: Cost-sharing in US prescription drug coverage plans for elderly persons varies widely. Evaluation of prescription drug use among elderly persons by type of health insurance could provide useful information for designing a Medicare drug program. OBJECTIVE: To determine use of effective cardiovascular drugs among elderly persons with coronary heart disease (CHD) by type of health insurance. DESIGN, SETTING, AND PATIENTS: Cross-sectional evaluation of 1908 community-dwelling adults, aged 66 years or older, with a history of CHD or myocardial infarction from the 1997 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. MAIN OUTCOME MEASURES: Use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), beta-blockers, and nitrates, and out-of-pocket expenditures for prescription drugs, stratified by type of health insurance: Medicare without drug coverage (Medicare only or self-purchased supplemental insurance) or with drug coverage (Medicaid, other public program, Medigap, health maintenance organization, or employer-sponsored plan). RESULTS: Statin use ranged from 4.1% in Medicare patients with no drug coverage to 27.4% in patients with employer-sponsored drug coverage (P<.001). Less variation between these 2 types occurred for beta-blockers (20.7% vs 36.1%; P =.003) and nitrates (20.4% vs 38.0%; P =.005). In multivariate analyses, statin use remained significantly lower for patients with Medicare only (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.49) and beta-blocker use was lower for Medicaid patients (OR, 0.55; 95% CI, 0.34-0.88) vs those with employer-sponsored coverage. Nitrate use occurred less frequently in persons lacking drug coverage (patients with Medicare only, P =.049; patients with supplemental insurance without drug coverage, P =.03). Patients with Medicare only spent a much larger fraction of income on prescription drugs compared with those with employer-sponsored drug coverage (7.9% vs 1.7%; adjusted P<.001). CONCLUSION: Elderly Medicare beneficiaries with CHD who lack drug coverage have disproportionately large drug expenditures and lower use rates of statins, a class of relatively expensive drugs that improve survival.

Aged↗
PubMed1998

The effect of employment status on private health insurance coverage: 1977 and 1987.

Analyzing cross-sectional data from the National Medical Expenditure Survey (NMES), we find that the predicted probability of private insurance coverage for low-income individuals as a group fell dramatically from 1977 to 1987. The results of a decompositional technique show that the relationship between full-time employment and private insurance has weakened over the period for low-income females, but has strengthened for males in this group. While it appears that low-income females benefit from part-time employment relative to their unemployed cohorts, no discernible difference is found in the likelihood of being covered by private insurance for part-time and unemployed males. Finally, evidence suggesting a weakening over time in the relationship between part-time employment and private insurance coverage is found among middle-income females and high-income males. From a policy perspective, passage of the Health Insurance Portability and Accountability Act of 1996 has taken an important first step in attempting to lower the number of uninsured, especially among full-time workers. Our findings, however, suggest that this legislation may be too limited in scope to effectively reach part-time workers presently uninsured.

Adolescent↗
PubMed1999

Community rating and choice between traditional health insurance and managed care.

This paper analyses the consequences of allowing a choice between traditional insurance and managed care under community rating. A model of a competitive health insurance market is developed; with the risk equalization scheme being imperfect. There are two types of individuals who are characterized by different costs with respect to traditional insurance. Compared with a situation where traditional insurance is compulsory, allowing choice can make both types better off, can increase the utility of low-cost types at the expense of high-cost types, as well as having no effect. Inefficiencies under compulsory traditional insurance can be eliminated and new inefficiencies can be created. Market equilibria are not necessarily second best.

Choice Behavior↗
PubMed1992

Financing a national health insurance.

Financing national health insurance is a topic that has been discussed for a long time in the United States. It is also of relevance for less developed countries, in particular in the Far East where some countries have just introduced or are on the brink of introducing national health insurance. Furthermore, there is an urgent need to consult those former socialist countries wishing to introduce a national health insurance system. The paper deals with basic principles of health insurance and specific elements of a (compulsory) social health insurance in detail.

Financing, Organized↗
PubMed2004

Race, ethnicity, insurance coverage, and preoperative status of hip and knee surgical patients.

Our objective was to examine the association between race/ethnicity and insurance type and the preoperative status of patients undergoing joint arthroplasty surgery. Quality of life and WOMAC measures were collected preoperatively in a consecutive series of patients undergoing primary hip or knee arthroplasties (n = 573). Non-Hispanic whites had lower preoperative pain and WOMAC scores and higher Quality Well Being Index and SF-36 scores compared with other racial/ethnic subgroups. Patients with Medicare/private insurance had better preoperative scores relative to patients with Medicaid or no insurance. Racial/ethnic status was generally more strongly associated with preoperative status than was insurance type. Hispanics, blacks, and patients without Medicare or private health insurance reach arthroplasty surgery with lower preoperative functional and health status.

Arthroplasty, Replacement, Hip↗
PubMed2006

Incentive-compatible guaranteed renewable health insurance premiums.

Theoretical models of guaranteed renewable insurance display front-loaded premium schedules. Such schedules both cover lifetime total claims of low-risk and high-risk individuals and provide an incentive for those who remain low-risk to continue to purchase the policy. Questions have been raised of whether actual individual insurance markets in the US approximate the behavior predicted by these models, both because young consumers may not be able to "afford" front-loading and because insurers may behave strategically in ways that erode the value of protection against risk reclassification. In this paper, the optimal competitive age-based premium schedule for a benchmark guaranteed renewable health insurance policy is estimated using medical expenditure data. Several factors are shown to reduce the amount of front-loading necessary. Indeed, the resulting optimal premium path increases with age. Actual premium paths exhibited by purchasers of individual insurance are close to the optimal renewable schedule we estimate. Finally, consumer utility associated with the feature is examined.

Adolescent↗
PubMedDate not supplied

Insurance coverage and health care use among near-elderly women.

OBJECTIVES: Data on near-elderly (ages 55-64) women's access to and use of health care have been limited. In this study, we sought to examine the status of near-elderly women's health insurance coverage in the United States and how it may influence their use of health care services. METHODS: A nationwide random sample of women aged 55-64 was drawn from the 2002 wave of the Health and Retirement Study. Descriptive statistics were calculated and multivariable regression analyses were performed to quantify the impact of insurance coverage on near-elderly women's use of outpatient services, inpatient services, and prescription medication over a 2-year period. RESULTS: In 2002, 9.4% of near-elderly women in the United States were uninsured and 15.4% had public coverage. Those who had coverage for a particular service were significantly more likely to use that service compared to women without coverage, with odds ratios ranging from 2.0-6.7 for services such as a physician visit, hospital stay, dental visit, and use of prescription medication. Among those who had at least one physician visit, near-elderly women who had some of the cost covered by insurance reported significantly more visits than women without coverage. Likewise, for near-elderly women regularly taking prescription medications, having more extensive coverage significantly increased their likelihood of medication adherence. The frequency of hospitalization was also higher for women who had complete coverage for the cost. CONCLUSIONS: The nature of a near-elderly woman's insurance coverage significantly affects her use of health care services. More attention is needed to improve the health care of near-elderly women with inadequate insurance coverage.

Attitude to Health↗
PubMed1997

Insurance status as a risk factor for foreign body ingestion or aspiration.

OBJECTIVE: To determine whether the lack of private health insurance places children at increased risk for foreign body ingestion or aspiration. DESIGN: Retrospective review. SETTING: St. Louis Children's Hospital, a tertiary care center. PATIENTS: Consecutive sample of 125 patients with esophageal or airway foreign bodies. RESULTS: Fifty percent of all patients had private health insurance. Fifty-six percent of all preschool patients and 20% of all school-age patients were uninsured (P < 0.01, Fisher's exact test). Eighty-five percent of patients with airway foreign bodies, and 84% of patients with esophageal foreign bodies were in the preschool group. Sixty-one percent of preschool patients and 21% of school-age patients with esophageal foreign bodies were uninsured (P < 0.05). Forty-six percent of preschool patients with food aspiration lacked health insurance (88% of these children were fed the aspirated item). No school-age group was available for comparison. Fifty percent of preschool children with aspiration of non food items were uninsured, as were 16% of their school-age counterparts. CONCLUSIONS: Insurance status must be considered as a risk factor for foreign body aspiration and ingestion. Preschool children are more likely to lack private health insurance than school-age children with the same diagnosis. In a majority of aspiration events, the child was being fed the inappropriate food item, perhaps indicating a lack of caretaker education and anticipatory guidance. A direct focus on 'passive protection', anticipatory guidance in clinics for all patients, and public education with emphasis on preventive care are proposed as means to decrease the incidence of airway and esophageal foreign bodies in children.

Age Factors↗
PubMed2001

Long-term care and nursing home coverage: are adult children substitutes for insurance policies?

Recent theoretical work suggests that in some cases, parents will forego the purchase of long-term care insurance and rely on child-provided care in old age. This paper uses data from the Asset and Health Dynamics survey and the Panel Study of Income Dynamics to examine whether the availability of children and other potential caregivers explains why so few elderly persons have long-term care insurance. In contrast to the notion that family members serve as substitutes for long-term care insurance, variables measuring the availability of informal caregivers have no statistically significant effect in models of insurance ownership and models of intentions to purchase insurance.

Adult↗
PubMed2001

A comment on Neudeck and Podczeck's "adverse selection and regulation in health insurance markets".

Using the Grossman equilibrium concept, Neudeck and Podczeck [Journal of Health Economics 15 (1996) 387] show that imposing a minimum standard on a perfectly competitive insurance market can result in anti-competitive effects: decreased welfare with some insurers earning positive profits. However, the Grossman concept precludes an insurer from offering two separating, cross-subsidizing health plans. When an insurer can offer multiple plans (as under both the Nash and Miyazaki-Wilson equilibrium concepts), I show that minimum standards result in a doubleton equilibrium, never allow positive total profits, and increase welfare. This is of interest since in 1997 more than half of establishments in the US offering choice of multiple plans did so through a single insurer.

Economic Competition↗
PubMed1997

Optimal non-linear health insurance.

Most theoretical and empirical work on efficient health insurance has been based on models with linear insurance schedules (a constant co-insurance parameter). In this paper, dynamic optimization techniques are used to analyse the properties of optimal non-linear insurance schedules in a model similar to one originally considered by Spence and Zeckhauser (American Economic Review, 1971, 61, 380-387) and reminiscent of those that have been used in the literature on optimal income taxation. The results of a preliminary numerical example suggest that the welfare losses from the implicit subsidy to employer-financed health insurance under US tax law may be a good deal smaller than previously estimated using linear models.

Canada↗
PubMed2003

Risky business: insuring adults with congenital heart disease.

Accurate prognostication in congenital heart disease is vital for purposes of obtaining insurance, yet can be problematic for patients, physicians and insurers. This article discusses the scope of the problem, and describes the process of evaluating life insurance. Mortality data as well as predictors of adverse outcomes for individual congenital heart lesions are reviewed. Practical tips for patients and their physicians are given to aid in successful application for insurance. To expand the possibility of future patients obtaining insurance coverage, the ongoing reporting and constant updating of very long-term survival data in congenital heart disease is emphasized.

Adult↗
PubMed2004

Risk segmentation and equity in the Chilean mandatory health insurance system.

For decades, the Chilean health system has included a requirement for dependent workers to spend a certain percentage of their wages on health insurance. Since 1981, workers have been able to choose between public insurance and several private insurance providers. The reforms introduced more choice, moving away from reliance on an exclusive public provider. By 1999, about half of the country's active dependent workers had opted out of the public and into the private insurance system. The development of the private insurance system has been accompanied by controversy, however, regarding possible inequities in the utilization of medical services, the degree of risk segmentation, inefficiencies in the system's operation, and other factors. This paper discusses the issues of risk segmentation and equity. It starts by reviewing the system's design on a theoretical level, then deriving hypothesis and finally providing empirical evidence regarding these hypothesis. Particular attention is given to the issues of how individuals choose between the public and private system (to determine the reasons behind risk segmentation) and the differences in utilization among the various income groups (to clarify the issue of possible inequities).

Actuarial Analysis↗