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PubMedDate not supplied

Incremental strategies for providing health insurance for the uninsured. Projected federal costs and number of newly insured.

OBJECTIVE: To present several incremental strategies for extending health insurance coverage for segments of an estimated 40.6 million uninsured persons in the United States. Along with these strategies, the federal costs and estimates of the number of newly insured are presented. DESIGN: Using data from the Congressional Budget Office and the federal government, the number of newly insured persons in the United States under options designed to increase coverage among uninsured children, their parents, and workers between jobs are simulated. The federal costs and coverage implications of these options are estimated for federal fiscal years 1998 through 2002. METHODS: Three distinct incremental approaches for covering the uninsured are explored. The first approach would expand coverage through the current Medicaid program. The second approach would provide financial incentives for parents of children eligible for Medicaid to purchase coverage, and the final approach provides time-limited subsidies allowing workers and their families to purchase insurance when they are between jobs. MAIN RESULTS: The federal costs of these approaches range from $2 billion to $3 billion per year (enrollment outreach approach) to $5 billion to $7 billion per year (enrolling parents of Medicaid-eligible children approach). If pursued simultaneously, the incremental strategies under investigation could extend health insurance to more than 7 million uninsured persons in the United States. The cost of these options could be financed through Medicaid savings, restructuring the current disproportionate share payments made through Medicare and Medicaid, increasing excise taxes on tobacco, or all of the above. CONCLUSIONS: The incremental strategies would build on the current US health care delivery system by providing targeted financial assistance to specific populations. By their nature, such reforms could provide a political means for compromise and agreement between Congress and the president. Though the reforms do not, by design, provide a comprehensive solution to the problems facing the uninsured, they would address the severe problems facing many low- and middle-income families unable to purchase health insurance today.

Adolescent↗

PubMed1998

Hospital charges to injured drinking drivers in Washington State: 1989-1993.

The Washington State Patrol Crash Database and computerized hospitalization records for 1989-1993 were used to determine total hospital charges billed for motor vehicle collision injuries to drivers whose crash reports contained any indication of alcohol use. In this population-based study, total hospital charges were summed, and mean charges and lengths of stay were computed within alcohol use and insurance coverage status categories in an attempt to evaluate the hospital charges billed to public funding and private insurance. Of the total hospital charges for drivers with injuries from motor vehicle collisions for which a police-reported indicator of alcohol use status was available, 43% (U.S.$64.8 million) were for drivers who reportedly had been drinking. At the time of discharge, Medicaid was identified as the payor for 47% of these hospitalizations. The mean hospital charge billed per collision was greater for drinking (U.S.$18,258) than nondrinking drivers (U.S.$14,181). Drinking drivers also had longer hospital stays, even after adjustment for patient age, gender and injury severity. During this time in Washington state, the average annual amount billed at discharge for initial inpatient care of injuries to drivers who reportedly had been drinking at the time of the motor vehicle collision was U.S.$13 million. This includes only the amount assessed by the hospital at the time of discharge for treatment of the initial injury and does not include other related medical charges for rehabilitation or outpatient care, or for doctors' or laboratory fees. As increasing pressures of managed and capitated care lead to a shift of financial risk from the federal government and insurers to states and providers, the financial burden of specific, potentially preventable conditions such as this will receive greater attention.

Accidents, Traffic↗

PubMed2005

A shared responsibility. US employers and the provision of health insurance to employees.

Employer-based health insurance is the backbone of the U.S. system of health insurance coverage. Yet it has been slowly eroding, and if these trends continue greater numbers of Americans are likely to be uninsured or without affordable coverage. Employer coverage has marked advantages, including benefits to employers and a natural risk pool that offers better benefits at lower cost than individual coverage, and is highly valued by employees. The shift of health care costs from employers who do not cover their workers to other parts of the economy is substantial. Very little attention has been given to policies that might strengthen and expand employer coverage. It will be important to shore up employer coverage both to curb its recent erosion and to build toward a more comprehensive system of health insurance.

Adult↗

PubMed2004

MassHealth succeeds in expanding coverage for adults.

This study provides the first rigorous evaluation of the impacts of MassHealth, Massachusetts' ambitious effort in the late 1990s to expand coverage to the entire low-income population. We find clear evidence that MassHealth led to an expansion of insurance coverage relative to what was happening to similar populations in comparison states. The success of MassHealth provides support for the value of investing in ambitious new state efforts to find effective strategies to reach the remaining uninsured populations. While current budget shortfalls have forced many states, including Massachusetts, to scale back their expansion efforts, the current economic downturn is not permanent. Understanding the impacts of the expansion efforts in Massachusetts adds to the base of knowledge that will be critical for guiding states when the economy recovers and the resources needed for expansion again become available.

Adult↗

PubMed1994

Retiree health insurance and pension coverage: variations by firm characteristics.

This study examined coverage by employer-sponsored retiree health insurance using the 1988 and 1989 Employee Benefits Surveys. The effects of firm characteristics on the probability of offering retiree health insurance and pension coverage are also estimated. We find that coverage by retiree health insurance varies across occupational groups, industries, and firm sizes. In addition, we find a strong relationship between a firm's decisions to offer retiree health insurance and pension coverage, with the retiree health insurance decision being more sensitive to specific firm characteristics.

Aged↗

PubMed1995

Are prescribed and over-the-counter medicines economic substitutes? A study of the effects of health insurance on medicine choices by the elderly.

This article examines the influence of insurance coverage on the selection of over-the-counter (OTC) and prescribed (Rx) medicines in treating less serious health problems. Because health insurance policies typically provide no coverage for OTC products, a low list price for an OTC may exceed the after-insurance expense associated with a much higher-priced prescription. Under these circumstances, rational individuals with insurance will choose prescribed medicines even if OTCs are equally effective. Ten common health problems typically managed with either Rx or OTC medicines were selected for analysis. The study population consists of elderly Pennsylvanians surveyed during 1990 who reported suffering one or more of these conditions (N = 2,962). Multivariate analysis confirmed that 1) people with prescription coverage are significantly more likely to medicate a given problem than are those without it; and 2) given the decision to medicate, the presence of insurance significantly increases the level of Rx use and significantly reduces the level of OTC use. As expected, the effect was strongest among people with the most complete prescription insurance coverage. The article discusses the implications of these findings in the context of national health reform and Food and Drug Administration policy regarding Rx-to-OTC switches.

Aged↗

PubMed2006

Coverage for mental health treatment: do the gaps still persist?

BACKGROUND: Consumers have long faced high out-of-pocket costs for mental health and substance abuse treatment in private health insurance plans, the predominant form of insurance coverage in the United States. Nominal mental health benefits may have improved from the mid-1990s onwards, as many states passed mental health parity mandates and other employers voluntarily improved coverage. However, the rapid rise of managed behavioral health care organizations (MBHOs) may have effectively offset these gains in nominal coverage. AIMS OF THE STUDY: We examine how effective mental health benefits, as measured by actual out-of-pocket expenses, compares to coverage for non-mental health treatment and how this has changed in recent years. METHODS: We used detailed data on health care use and expenses from the nationally representative, Medical Expenditure Panel Survey (MEPS) to describe the distribution of out-of-pocket expenses for mental health and non-mental health ambulatory visits and prescription drug fills and demonstrate how this changed between 1996 and 2003. In addition, we use two-limit tobit regression models to descriptively examine the factors associated with higher out-of-pocket costs for ambulatory mental health treatment. RESULTS: While out-of-pockets shares generally decreased over the 1996-2003 period, from 39 to 35 percent of total expenses for ambulatory mental health visits and from 31 to 26 percent for non-mental health ambulatory visits, the ratio of out-of-pockets costs is still significantly higher for mental health care. Out-of-pocket expenses per visit fell as the number of non-mental health visits increased but out-of-pocket expenses for mental health visits rose with more visits. Out-of-pocket expenses for visits to specialty mental health providers were substantially higher than for non-psychiatrist physicians. Though prescription drug spending increased substantially, the percent paid out-of-pocket did not change for mental health and non-mental health related fills. DISCUSSION: Our results suggest that expenses for ambulatory mental health visits, especially for specialty providers, effectively remain less well covered than other medical visits. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Continued high out-of-pocket expenses for mental health treatment may impede access to mental health treatment, especially for those who need greater treatment intensity. IMPLICATIONS FOR HEALTH POLICIES: Mental health parity may not ensure that coverage for mental health services is, in actuality, equal. IMPLICATIONS FOR FURTHER RESEARCH: Additional research is needed in understanding relative changes in nominal vs. actual or effective coverage.

Adult↗

PubMed2000

Uninsured under TennCare: a case study of public health clinic users.

BACKGROUND: We characterized public health clinic users 4 years after implementation of a major public health insurance reform and identified barriers to health care access. METHODS: We used face-to-face interviews and profile analysis of survey findings. RESULTS: The typical public health client household is larger, poorer, and more likely to be black than the wider population. The health status of participants is generally good; the level of insurance coverage is preponderantly TennCare; and 90% of respondents are willing to pay some premium. CONCLUSIONS: Lack of health insurance does not present a serious health care access barrier, nor do transportation or location; but taking time off from work with loss of wages is a problem for those employed. A cost-effective way to enroll uninsured children is to use the County Health Department clinics as a contact point.

Adult↗

PubMed1958

Analysis of your professional liability insurance policy.

The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for "latent liability" claims as the years go along-certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.

Insurance↗

PubMed2006

Charge of the right brigade? Communities, coverage, and care for the uninsured.

The Robert Wood Johnson Foundation's Communities in Charge (CIC) program funded projects in fourteen communities that aimed to expand health insurance coverage and improve care for their uninsured residents. Our examination of seven program sites suggests that despite solid community leadership and carefully crafted plans, political, economic, and organizational obstacles precluded much expansion of coverage and constrained reforms. Redistribution of financial and organizational resources among both mainstream and safety-net institutions in these communities was hard to achieve. CIC's record offers little evidence that communities are better equipped than are other sectors of U.S. society to solve the problem of uninsurance.

Community Health Planning↗

PubMed1986

Work therapy and return to work.

In summary, data were selected for 1 year on patients treated in the Work Tolerance Program at the Hand Rehabilitation Center in Philadelphia. The type of information obtained has been used to obtain a profile of the patient population in the Work Tolerance Program. Statistical analysis was used, not only to formulate patient demographics, but also to evaluate the length of treatment of patients in the Work Tolerance Program. This period averaged 6 weeks. The statistical analysis also revealed there was significant interaction between the type of injury and the patient's diagnosis, and the rate of return to work. The patients with injuries to bone and nerve required longer periods of treatment until they returned to work than did patients with injuries to soft tissue or combination injuries. Our statistical analysis revealed that in 1982, 75 per cent of the patients in the Work Tolerance Program returned to work to regular or modified jobs. The length of time from injury to return to work was 63 per cent longer for patients with Workers' Compensation coverage than for patients with private insurance coverage. Because the statistical analysis that 60 per cent of the patients treated in the Work Tolerance Program were Workers' Compensation insured, and 80 per cent of the patients treated in the Work Tolerance Program were secondarily referred, it should be recognized that all patients with severe hand injuries would benefit from an immediate referral to a Hand Rehabilitation Center of excellence to facilitate their therapeutic management and expedite their recovery from time of injury to return to work. This study was restricted to the analysis of length of treatment and rate of return to work. Future studies should study the effect of early referral and the application of specific treatments.

Adult↗

PubMedDate not supplied

Validity of self-reported health plan information in a population-based health survey.

OBJECTIVE: To validate information on private health insurance coverage in a population-based study. METHODS: Respondents to the Massachusetts Behavioral Risk Factor Surveillance System were asked the name of their health plan company (affiliation) and specific brand of insurance (product), the duration in which they belonged to the plan, and demographic and health-related data. Information on plan affiliation and product was used to classify individuals on type of coverage. At the end of the survey, respondents with health insurance were asked to retrieve their health plan cards, and to read detailed information from the cards. Self-reported data were compared with information from the cards. RESULTS: Self-reported information on health plan affiliation agreed with plan cards for 93 percent of individuals, while agreement was 79 percent for health plan product. Among health maintenance organization (HMO) participants, 93 percent correctly reported being in an HMO (sensitivity), whereas 76 percent of respondents in a non-HMO plan correctly self-reported (specificity). Individuals with higher levels of income, those with a primary care doctor, and those in a health plan for at least 1 year had higher agreement. Higher validity was associated with poor physical health and recent cancer screening. CONCLUSIONS: Self-reported data on health plan affiliation and product have good validity in a population-based sample of adults. While agreement differs according to specific respondent characteristics, these differences do not appear substantial.

Adolescent↗

PubMedDate not supplied

Hospital-affiliated pediatric urgent care clinics: a necessary extension for emergency departments?

This study analyzed whether a children's hospital urgent care clinic helped increase market share. Patient demographics and utilization patterns between the suburban clinic and urban emergency department were compared over a three-year period (July 1999 to June 2002). Using data from a standardized billing form, all patient visits (clinic: 36,924; emergency department: 160,888) were analyzed. Variables included patient visitation date, age, gender, race, primary insurance carrier, primary diagnosis, and primary residence Zip code. Differences between the after-hours clinic and emergency department included: more private insurance coverage (83% and 35%, respectively); less no insurance/Medicaid/State Children's Health Insurance Program (SCHIP) coverage (16.4% and 55%, respectively); and more Caucasian patients (80% and 35%, respectively) at the off-site clinic; thus usage was more similar with that of a physician's office than an outpatient clinic. Symptoms seen in the after-hours clinic were primarily respiratory, ear, and throat related. In the emergency department, the symptoms were more varied, primarily febrile, respiratory, ear, throat, gastrointestinal, and urinary tract problems. There was a 3.6% increase in the number of visits in the after-hours clinic and a 1.6% decrease in the number of emergency department visits between year one and year three--data combined giving an overall 4.8% increase in the number of visits. Data show that the offsite urgent care clinic located in a suburban area increased the overall number of visits with a large number of well-insured patients. Additionally, this study provided data on where the clinic could expand medical care for the community.

Adolescent↗

PubMed2001

Hypertension outcomes in an urban nurse-managed center.

PURPOSE: To assess the quality of hypertension (HTN) care in an urban nurse-managed center (NMC) by chart audits of insured and uninsured (N = 52) African Americans who were managed by nurse practitioners. DATA SOURCES: A chart audit form was developed by the authors that merged Health Plan Employer Data and Information Set (HEDIS) criteria with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria. CONCLUSIONS: There was near comparable hypertension control among the two groups. No difference was found in systolic blood pressure (BP) control; however, the uninsured group had a slightly greater average diastolic BP compared with the insured group. There was no significant difference in the number of HTN medications or the number of risk factors. A significant difference was found in the number of NP visits per year between the two groups; the uninsured group averaged 3.2 more visits per year. IMPLICATIONS FOR PRACTICE: Nurse practitioners in this NMC were able to manage HTN in a high-risk population despite a lack of insurance coverage for anti-hypertensive prescriptions. The finding that the uninsured group had more clinic visits per year than the insured group is significant in that it increases the cost of providing care for these patients and the health care system. The patient cost in time, transportation and burden needs further assessment.

Antihypertensive Agents↗

PubMed1989

Cost estimate of health care coverage for the medically indigent in Hawaii.

The objective of the study was to estimate the cost of health insurance coverage of the medically indigent in Hawaii. The number of uninsured was estimated deductively from the coverages of those insurance companies doing business in the state, with an additional factor for persons with more than one policy coverage. Age and sex breakdowns of the uninsured were entered into actuarial tables and fee-for-service and HMO plan costs were obtained for the most prevalent health plan in the state. Annual coverage is estimated at US$46.090866 million and US$58.040700 million for fee-for-service and HMO plans, respectively. Seven potential sources of financing and five recommendations for further research are given.

Actuarial Analysis↗

PubMedDate not supplied

Barriers to postpartum depression prevention and treatment: a policy analysis.

Public policy erects two barriers to adequate prevention and treatment of postpartum depression (PPD) in the United States: 1) the lack of parity between insurance coverage for mental and physical illness decreases access to care and 2) the current model of postpartum care fails to incorporate screening and follow-up. Treatment for PPD falls into the insurance category of mental health. But many insurance companies either do not cover mental illness at all or provide coverage that is far below that for physical ailments. Because cost-benefit analyses have shown the benefits of parity laws, legislation to achieve parity between mental and physical health insurance is crucial in addressing this problem. Meanwhile, the U.S. model of post-partum care should follow the example of care provided in the United Kingdom where nurse-midwives visit new mothers at home to check on their physical and emotional status. In one program that produced positive psychological health outcomes, midwifery visits were tailored to individual needs and extended to 10-12 weeks postpartum. Encouraging developments in the United States include 1) an effective program that screens new mothers with signs of PPD and provides telephone follow-up and rapid treatment referral and 2) proposed legislation to fund organizations working to reduce the incidence of PPD.

Adult↗

PubMed2002

Loss of health insurance and the risk for a decline in self-reported health and physical functioning.

BACKGROUND: Millions of Americans are intermittently uninsured. The health consequences of this are not known. SETTING: National survey. PARTICIPANTS: Six thousand seventy-two participants in the Health and Retirement Study (HRS) age 51 to 61 years old with private insurance in 1992. MEASUREMENTS: Loss of insurance coverage between 1992 and 1992 and development of a major decline in overall health or a new physical difficulty between 1994 and 1996. RESULTS: In 1994, 5768 (95.0%) people continued to have private insurance, 229 (3.8%) reported having lost all insurance, and 75 (1.2%) converted to having only public insurance. Over the subsequent 2 years (1994-1996), the risk for a major decline in overall health was 15.6% for those who lost all insurance versus 7.2% for those with continuous private insurance (P <0.001). After adjusting for baseline sociodemographics, health behaviors, and health status, the adjusted relative risk for a major decline in health for those who lost coverage was 1.82 (95% CI, 1.25-2.59) compared with those with continuous private insurance. Those who lost insurance also had a higher risk for developing a new mobility difficulty compared with those with continuous private insurance (28.5% vs. 20.4%, respectively; P= 0.02), but this was not significant in multivariate analysis (adjusted RR, 1.26; 95% CI, 0.90-1.68). CONCLUSIONS: Loss of insurance has adverse health consequences even within 2 years after becoming uninsured. Studies of insurance coverage should routinely measure the number of Americans uninsured at any time over the preceding 2 years as a more accurate measure of the population at risk from being uninsured.

Female↗

PubMed2001

Wisconsin's BadgerCare program offers innovative approach for family coverage.

Wisconsin's BadgerCare program is viewed by many as a model for how other states could pursue comprehensive health insurance coverage for lower income families. The program provides health insurance to working families - both children and their parents - and seeks to eliminate barriers to successful employment by providing a transition for families from welfare to private insurance. BadgerCare's success is founded on its family coverage approach, its single point of entry and administrative seamlessness, and the political commitment to the program from Governor Tommy G. Thompson. In 1999 and 2000, New York, New Jersey, and the Clinton administration recognized the importance of a family-based approach to children's coverage by proposing, and in the states' case, implementing some variation of the Wisconsin model. Other states have indicated interest in covering families and look to the flexibility of the Health Care Financing Administration's (HCFA) recent ruling on 1115 demonstration projects to cover parents using the enhanced State Children's Health Insurance Program (SCHIP) match. This case study details the BadgerCare program and its impact on the uninsured in Wisconsin, including how the program approaches enrolling families, how family coverage is financed, how the program partners with private insurance, and what cost-sharing obligations exist.

Adult↗