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PubMed1994

Notes from the insurance underground: how the chronically ill cope.

This report from the field is an account of the experience of individuals with multiple sclerosis (MS) in Indiana in getting and keeping private health insurance. The report presents the findings of a telephone survey of individuals with MS in Indiana. While survey respondents were generally able to obtain health insurance through the Medicare program or employer-based private health insurance plans, many experienced formidable barriers to adequate and affordable health insurance, such as preexisting exclusions, cancellations, high premiums, and coinsurance. Respondents adopted a variety of strategies to keep private health insurance, including selectivity in submitting claims, which worked to reduce their health insurance coverage. Our findings raise two crucial questions: (1) to what extent are the chronically ill forced to take extraordinary measures to get and keep health insurance? and (2) to what extent do insurer practices in pricing insurance and determining coverage of benefits actually make health insurance even more inadequate and unaffordable for the chronically ill? These two questions are critical in understanding the full dimensions of the health insurance crisis in the United States today.

Actuarial Analysis↗
PubMedDate not supplied

The role of public employers in a changing health care market.

Public employers provide health insurance coverage to nearly 16 percent of all U.S. workers. Their reactions to rapidly rising premiums can have an important effect on local markets for health insurance because of their size, their visibility, and their reflection of public policy. However, public employers are constrained in their responses by tight budgets set by elected officials and statutes regarding due process, public input, and public accountability. As insurance markets consolidate and premiums continue to increase, public employers face tough choices regarding employee benefits.

Budgets↗
PubMed2003

Medicaid and indigent care issue brief: Medicaid: eligibility: year end report-2003.

Medicaid provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. In 1999, Medicaid provided health care insurance to approximately 32 million low-income Americans. However, in that same year, 42 million Americans had no health insurance at all. In order to reduce the number of people without health insurance, states have expanded or clarified their eligibility standards to allow more people to enroll in Medicaid and other medical assistance programs.

Aged↗
PubMed2006

Gender differences in the management of risk factors for cardiovascular disease: the importance of insurance status.

Despite cardiovascular disease (CVD) being the leading killer of both sexes in the US, there are indications that men and women have different experiences in the health system with prevention and treatment practices. Beyond largely descriptive findings, little research exists that addresses how men and women may differ in their response to certain key influences on CVD health services utilization. This paper examines gender differentials in the effect of insurance coverage on CVD preventive health services in the US. An economics framework is used to model individual demand for preventive services as a function of insurance status, while controlling for a comprehensive set of explanatory variables. The services analyzed include cholesterol and blood pressure screening, pharmaceutical use for hypertension and lipid disorders, and CVD-related physician visits. Both general and high-risk samples are evaluated. The results show that while a lack of insurance is associated with lower rates of utilization in both men and women, there are no observed gender differences in insurance-effects for recommended intervals of risk factor screening in the general population. However, for individuals with previously diagnosed heart disease or stroke, a lack of coverage is more strongly associated with lower rates of screening, pharmaceutical management, and physician contact in women than men. Potential reasons for these findings are discussed and policy implications are noted.

Cardiovascular Diseases↗
PubMed2006

Discharge destination from acute care after traumatic brain injury.

OBJECTIVE: To identify the impact of private insurance coverage on discharge disposition after a traumatic brain injury (TBI) using injury in a motor vehicle accident (MVA) as a proxy for private insurance, controlling for age and severity of injury. METHOD: Cross-sectional study. PATIENTS: Patients with TBI discharged between 1993-1994 and 2000-2001 (n = 9,703). MAIN OUTCOME MEASURE: Discharge destination from acute care; controlled odds ratio (OR) and confidence interval (CI) for type of injury. RESULTS: Type of injury, age, and length of stay are significantly associated with discharge destination. However, the motor vehicle accident patients are 56% more likely to be discharged to home with support services than patients with similar injuries from falls. CONCLUSION: Even in a system with universal coverage, availability of private insurance type is a potential independent determinant of post-acute care services. More research is required to determine the effect this relationship has on the cost and outcomes of care for TBI patients.

Accidental Falls↗
PubMed1997

Medicaid participation among the eligible elderly.

This study uses data from the Survey of Income and Program Participation to address three issues: (1) what were the 1987 rates of Medicaid participation and private insurance coverage among elderly predicted to be categorically eligible and medically needy?; (2) how did these rates change between 1987 and 1992?; and (3) which factors influence insurance choices among persons who are categorically eligible for Medicaid? The 1987 Medicaid participation rates were 64 percent for the categorically eligible, but only 11 percent among the medically needy. Participation among the categorically eligible declined to 59 percent by 1992, but the difference was insignificant. In both years, about 23 percent of all categorically eligible persons had private insurance, but among those who do not participate in Medicaid, the rate rises to 48 percent.

Aged↗
PubMed1999

Health insurance, health reform, and outpatient mental health treatment: who benefits?

This research examines how extending health insurance coverage to the previously uninsured impacts outpatient mental health treatment use among adults with different needs. Using data from the Epidemiologic Catchment Area Study and the 1987 National Medical Expenditure Survey, I develop simulations based on estimates of treatment demand. I find that insurance substantially increases demand by the mentally ill, but increased coverage alone cannot meet their treatment needs. Those in better mental health account for significant proportions of additional demand when coverage is expanded. Policies intended to increase access to mental health treatment among targeted groups should carefully consider the costs of increased use by other people.

Adult↗
PubMed2005

Factors influencing the shift of patients from one proton pump inhibitor to another: the effect of direct-to-consumer advertising.

BACKGROUND: Switching from one proton pump inhibitor (PPI) to another is common, and may be related to factors other than efficacy and tolerability. OBJECTIVES: The purposes of this study were to describe the incidence of therapeutic switching among PPI users, quantify direct ambulatory medical costs of switching, and characterize the relationship between product switching and variables hypothesized to influence a switch (eg, direct-to-consumer [DTC] advertising, structure of insurance coverage, disease diagnosis). METHODS: This was a retrospective cohort study of health plans using 1998 data. The subjects were employees and dependents with employer-sponsored health insurance contributing to the Medstat Market-Scan administrative dataset. Using a commercially available database to quantify DTC advertising by marketing area, market-specific expenditures were matched to eligible subjects. Among PPI users, we identified those who switched from one product to another (switchers) and compared their utilization and spending with nonswitchers. We then evaluated the relationship between drug use and variables hypothesized to affect switching: DTC advertising, insurance characteristics, patient diagnosis, diagnostic procedures, comorbidities, age, and sex. RESULTS: The analysis used data for 396,500 individuals from 47 unique markets that were geographically well distributed, with population density similar to that of the United States overall. The sample was also comparable with US census estimates for age and sex among working adults and their dependents. Only 620 (6.3%) of PPI users switched products during the 1998 calendar year. Annual diagnostic and drug costs were >US $400 higher for switchers than nonswitchers. Subjects in areas with high levels of DTC advertising were 43% more likely to switch from lansoprazole to omeprazole than those in the low-expenditure areas. Additionally, patients paying prescription drug copayments >US $5 were 12% less likely to switch from lansoprazole to omeprazole than patients paying lower copayments. CONCLUSIONS: In these privately insured patients using PPIs, product switching was associated with increased treatment costs. DTC advertising and patient cost-sharing were important predictors of product switching.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMedDate not supplied

Employers' responses to a play-or-pay mandate: an analysis of California's Health Insurance Act of 2003.

California recently enacted a play-or-pay employer mandate (known as SB 2) to expand health insurance coverage to a portion of the state's working uninsured population. Implementing SB 2 will change the behavior of employers affected by the legislation, with consequences for California's labor market and uninsured citizens. This paper applies findings from the literature and an economic analysis to California data to estimate the potential reduction in wages, quantify the dispersion of risk across employers, and discuss other employment effects. These employer responses will reduce the number of uninsured people in California who gain eligibility for health coverage under SB 2.

Adult↗
PubMed1991

Universal access to health care. A comprehensive tax-based approach.

More than 30 million Americans lack health insurance, and millions more are "underinsured." Meanwhile, the cost of health care in the United States is escalating, and some of our care is of questionable value. This article presents a health care reform strategy that addresses these three fundamental problems in the US health care system. The strategy, designed to empower consumers to make cost-conscious health care choices, combines a universal tax credit that enables all Americans to purchase basic health coverage; insurance reforms including pooling and reinsurance mechanisms; requirements that all employers make insurance available to their employees and that all consumers purchase coverage; and efforts to measure and improve the quality and efficiency of health care services. This strategy would help us to achieve universal health insurance coverage, while creating the proper incentives for cost control. In addition, it can be largely internally financed through savings automatically triggered by its implementation.

Cost Control↗
PubMed1998

Do people shift their use of health services over time to take advantage of insurance?

This paper provides a test of the hypothesis that people shift their consumption of health services to time periods when they have more generous insurance coverage, in order to take advantage of third-party payment. We use data from the Survey of Income and Program Participation to compare utilization rates for people in transition between being insured and being uninsured to those of people who are continuously insured and continuously uninsured. We find little support for the hypothesis that people anticipate changes in their insurance status and arrange their health care consumption accordingly.

Data Collection↗
PubMed2004

Unequal access: insurance instability among low-income workers and minorities.

Analysis of health insurance coverage and employment patterns from 1996 through 1999 reveals even higher uninsured rates and greater insurance instability among low-income adults and minorities than had been previously documented. Most low-income adults worked during the four years, but many had no or only intermittent job-based coverage. Low-income Hispanic adults were particularly hard hit: more than one-third (37%) of this group were never insured with private coverage, even though they worked all four years. Policies that expand coverage to low-income families could help reduce racial and ethnic disparities in access to care.

Adult↗
PubMed1998

Sources of health insurance and characteristics of the uninsured: analysis of the March 1998 Current Population Survey.

This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the characteristics most closely related to individuals' health insurance status. Based on EBRI analysis of the March 1998 Current Population Survey, it represents 1997 data--the most recent data available. In 1997, private or public health insurance, or both, covered 81.7 percent of Americans (193.1 million) at some point. Seventy-one percent of the nonelderly population had private insurance, 64.2 percent through an employment-based plan. Almost 15 percent of the nonelderly had public health insurance. In 1997, 18.3 percent of the nonelderly population was uninsured, compared with 14.8 percent a decade earlier, in 1987. The percentage of uninsured Americans has been increasing since at least 1987. While the increase in the uninsured between 1987 and 1993 can be attributed to the erosion of employment-based health benefits, the portion of Americans covered by employment-based health insurance increased between 1993 (63.5 percent) and 1997 (64.2 percent). The decline in public sources of health insurance would mostly explain the recent increase in the uninsured population. For example, between 1994 and 1996 the percentage of nonelderly Americans covered by CHAMPUS/CHAMPVA declined from 3.8 percent to 2.9 percent, in large part due to downsizing in the military. Similarly, between 1996 and 1997, the percentage of nonelderly Americans covered by Medicaid (the federal-state insurance program for the poor) declined from 12.1 percent to 11.0 percent as people left welfare for the private sector. This follows a decline in Medicaid participation between 1995 and 1996. Between 1996 and 1997 the percentage of nonelderly Americans without health insurance coverage increased from 17.7 percent to 18.3 percent. Further examination indicates that adults ages 18-64 accounted for almost all of this increase. In 1996, 14.8 percent of children and 18.9 percent of persons ages 18-64 were uninsured, compared with 15.0 percent of children and 19.7 percent of persons ages 18-64 in 1997. The decline in Medicaid coverage among nonworking and working adults appears to account for the overall increase in the uninsured. Employment and income play a dominant role in determining an individual's likelihood of having health insurance. In addition, age, gender, firm size, hours of work, and industry are all important determinants of an individual's likelihood of having coverage; however, these variables are also closely linked to employment status and income. Some of the widest variations involve factors that are not always examined in traditional demographic assessments, such as citizenship. However, variations by race, ethnicity, and citizenship are also closely linked to employment status and income.

Adolescent↗
PubMed1993

Insuring Latinos against the costs of illness.

OBJECTIVE: To examine the determinants of health insurance coverage for Latinos in the United States and how different targeted strategies for health care reform differentially affect the country's major ethnic groups, focusing on the implications for the Latino population. DESIGN: Data from the 1980 and 1990 Current Population Surveys were used to compare the insurance status of nonelderly (< 65 years) Latinos with the Anglo (non-Hispanic white), black, and Asian and other populations by estimating the attributable fraction for selected covariates. The effects of health care reform strategies on the coverage of the major ethnic groups were simulated from these data. MAIN OUTCOME MEASURES: Percentage uninsured, percentage insured by Medicaid, and attributable fraction for covariates. RESULTS: Latinos have the worst health insurance coverage of any ethnic group in the country. Approximately 39% of Latinos are uninsured compared with 13.8% for the Anglo and 24% for the black population. Providing coverage to all the poor could reduce the uninsured rate for Anglos by about 23%, whereas the reduction among Latinos could be about 37% and among blacks about 42%. Similar reductions could be achieved by covering all workers and their minor dependents. Regardless of the approach to reform, however, Latinos would remain with high absolute rates of uninsured. CONCLUSIONS: Differences in Medicaid eligibility, labor force characteristics, and family composition between Latinos and other ethnic groups suggest that policy initiatives may affect Latinos differently. Targeted strategies, such as employer mandates, "pay-or-play" programs, or Medicaid expansions, can improve coverage, but many Latinos could still remain uninsured.

Adolescent↗
PubMed1999

The impact of insurance status on drug abuse treatment completion.

This article discusses the impact of insurance status on drug abuse treatment completion in a not-for-profit organization, presents demographic findings, mentions financial obstacles to paying for treatment, and describes the relationship between different variables: treatment modalities versus type of drug, treatment modality versus length of stay, reason for discharge versus type of drug, and reason of discharge versus treatment status (completed/not completed). Baseline data (n = 6,539) for the period 1990-1997 was analyzed. For the insurance status analysis we randomly selected and analyzed 1,153 client entries. A statistical software package (STATA) was used for a combination of bivariate and multivariate analysis. Our results indicated, consistent with expectations, that lack of health insurance is associated significantly with not completing treatment. Therefore, new strategies and mechanisms of payment should be created to overcome these obstacles and facilitate treatment completion for clients without insurance coverage.

Ambulatory Care↗
PubMed1992

Use of medical insurance claims for surveillance of occupational disease. An analysis of cumulative trauma in the auto industry.

Medical insurance claims, linked with work histories for a large automotive manufacturer over a 3-year period, identified large numbers of cases of potentially work-related diseases, including 30,600 episodes of probable cumulative trauma disorders (CTD). CTD incidence rates were calculated within five plants, and high-risk areas identified, however, unknown differences in medical insurance coverage by exposure group limited interpretation. Case-control analyses, with controls also identified by insurance claims, addressed coverage and produced age-adjusted and sex-adjusted estimates of risks. All five plants had departments with statistically significant, elevated risks for one or more of the diagnoses carpal tunnel syndrome, CTD of other upper extremities, rotator cuff syndrome, CTD of the neck and of the lower back. Medical insurance claim data linked with work history provide the basis for practical and comprehensive surveillance for CTD and potentially a variety of other occupational diseases.

Accidents, Occupational↗
PubMed2001

Interim final rules for nondiscrimination in health coverage in the group market. Internal Revenue Service, Department of the Treasury; Pension and Welfare Benefits Administration, Department of Labor; Health Care Financing Administration, Department of Health and Human Services. Interim final rules with request for comments.

This document contains interim final rules governing the provisions prohibiting discrimination based on a health factor for group health plans and issuers of health insurance coverage offered in connection with a group health plan. The rules contained in this document implement changes made to the Internal Revenue Code of 1986 (Code), the Employee Retirement Income Security Act of 1974 (ERISA), and the Public Health Service Act (PHS Act) enacted as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Employee Retirement Income Security Act↗
PubMed1997

Patient-specific predictors of ambulance use.

STUDY OBJECTIVE: To determine patient-specific socioeconomic and health status characteristics for patients arriving by ambulance at an emergency department. METHODS: Ambulance use among adult ED patients presenting with abdominal pain, chest pain, head trauma, or shortness of breath was studied at five urban teaching hospitals in the north-eastern United States. Cross-sectional analysis within a prospective cohort study of 4,979 consecutive patients was performed using an interval sequence subset of 2,315 patients (84% of those eligible) to whom questionnaires were administered. Ambulance use (21% of surveyed patients; 26% of all patients) was analyzed with logistic regression. RESULTS: Predictors of ambulance use included age greater than 65 years (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.34 to 2.82); clinical severity (OR, 3.11; 95% CI, 2.27 to 4.25); poverty (OR, 1.40; 95% CI, 1.08 to 1.83); physical function (OR, 1.05; 95% CI, 1.02 to 1.09 for each point of worsening function on a 12-point physical function scale); and various types of health insurance coverage. Race, sex, education, Medicaid coverage, frequency of ED use, living arrangements, and primary physician availability were not predictive in multivariate analysis of surveyed patients. CONCLUSION: Ambulance use varies by age, clinical severity, income, patient-specific characteristics of physical function, and type of health insurance. Medicaid coverage and frequent ED use are not predictive of increased ambulance use.

Acute Disease↗