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Lack of reimbursement for pit and fissure sealants by third-party payers is frequently cited as a major barrier to increased use by dental practitioners. An increase in insurance coverage for sealants since January, 1984 may facilitate practitioners' use of the procedure, ultimately improving the public's oral health.
BACKGROUND: Although several studies have reported the effects of free medical care on compliance in patients with hypertension, no study has reported the effects of an economic incentive, such as subsidized medical costs, on compliance with medication protocol, in patients with hypertension. The unique characteristics of the Japanese health insurance system provide for a 10% decrease in the subsidy for medication immediately on retirement (approximately 60 years of age) for insured patients, and a 100% subsidy for insured patients who are 70 years of age or older. We examined the association between level of health insurance coverage and follow-up rate of medical treatment among Japanese patients with hypertension. METHODS: The subjects, from throughout Japan, were patients with hypertension (n=1236). The study was conducted in 1991. The odds of completing a 1-year treatment in relation to the rate of health insurance reimbursement were calculated using multiple logistic regression analysis. RESULTS: We found the following. (1) Compared with the base group, the odds of completing a 1-year treatment increased to 2.62 or 2.51 in the group whose reimbursement rate was 100%. (2) Compared with the base group, the odds of completing a 1-year treatment was no larger than 1 in the group whose reimbursement rate had been 100% for more than 6 years ('76-'). (3) Compared with the base level, the odds of completing a 1-year treatment increased to 1-1.81 in the group whose liability decreased to 80%. CONCLUSION: Although the results imply that even a small economic incentive might be effective in securing a patient's compliance with anti-hypertensive medical treatment, the effect appear limited in both duration and magnitude.
The Massachusetts plan to extend health insurance coverage to nearly all of the state's residents offers several lessons related to health reform, including the following: Bipartisan cooperation is possible; multiple policy mechanisms must be employed to achieve meaningful change; the starting point-in terms of the rate of uninsurance, the degree of insurance market regulation, and so on-matters; and implementation details are critical. In addition to these lessons, we argue that objective analysis and a comprehensive framework for evaluating alternative policy options are needed for similar reforms to be enacted elsewhere.
The American public increasingly finds itself disenchanted with the system for health care financing in this country. Three forms of reform proposal are examined: those that place the locus of primary responsibility for health insurance coverage on the individual, those that would rely on employer mandates with patients and government bearing the residual responsibility, and those that lodge chief financial responsibility with the government, and act as primary agent for cost control. The second approach, government-mandated employer-provided health insurance, appears to be the most politically viable at this time. However, that option is likely to be acceptable to the business community only if the mandate is coupled with additional regulation of private health insurance. Specifically, private health insurance in such a system likely would be based on mandatory open enrollment, community-rated premiums, and all-payer reimbursement, under which every payer pays a given provider the same fee for the same service.
Investigated the characteristics predictive of long-term stay in private practice psychotherapy in a population of 64 "long-term" clients (remained longer than 25 sessions, mean = 47 sessions) and 88 "short-term" clients (terminated before 25 sessions, mean = 7 sessions). Data consisted of T-scores on the intake MMPI and two variables (possession of insurance coverage and use of psychoactive medication) on which long and short-term clients had been found to differ in other research. Stepwise multiple regression analysis was performed and revealed that MMPI scales 2 and 0 added to the prediction of length of stay in psychotherapy (p < .01). Insurance and medication were significant predictors only when MMPI data were not used.
BACKGROUND/METHODS: Relatively little is known about the size and makeup of the growing population of cancer survivors or about the social implications of a diagnosis of cancer. To explore these issues, we analyzed cancer survivorship information from the 1992 National Health Interview Survey (NHIS), and resulting cancer prevalence estimates were compared with those derived from cancer registry data. RESULTS: According to the NHIS, there were an estimated 7.2 million adult survivors of cancer-excluding nonmelanoma skin cancer-in 1992, representing 3.9% of the U.S. adult population. Comparisons with prevalence estimates from cancer registry data suggest that cancer is underreported in the NHIS. Nearly three fifths (58.0%) of cancer survivors self-identified on the NHIS reported that their cancer was first detected when they noticed something wrong and went to a doctor. The majority (55.7%) of cancer survivors had obtained a second opinion or multiple opinions regarding their treatment. Most (58.0%) had received patient educational materials from a health care provider. However, relatively few had received counseling or participated in support groups (14.2%), contacted cancer organizations after their diagnosis (10.9%), or participated in a research study or clinical trial as part of their cancer treatment (4.7%). One ninth (10.7%) of the survivors had been denied health or life insurance coverage because of their cancer. Nearly one fifth (18.2%) of the cancer survivors who worked before or after their cancer was diagnosed experienced employment problems because of their cancer. CONCLUSIONS: While cancer appears to be underreported on the 1992 NHIS, the survey provides valuable information about the medical, insurance, and employment experience of cancer survivors selected from a nationally representative sample of U.S. households.
In October 1999, the BC Court of Appeal denied the request of the Canadian AIDS Society (CAS) and the BC Persons with AIDS Society (BCPWA) to intervene in the appellate hearing of a case raising questions about the responsibilities of employers and employees to preserve entitlement to life insurance coverage. In this case, the issue of the mental capacity of a man with AIDS-related dementia was a key issue.
The Canada Health Act provides a framework for the Canadian health system and a mechanism for federal healthcare funds to flow to the provinces. Presently, the Canada Health Act covers medically necessary hospital, physician and surgical-dental as well as limited long-term care services, but not prescription medication. Though not mandated, each province has chosen to also develop a prescription drug benefit plan. These plans differ with respect to the groups that are covered and the type of coverage provided. In this paper, we describe the key structural elements of the various provincial plans. In addition, using a population-based national health and mental healthcare survey of 33,000 Canadians, we explore the characteristics of the population currently not covered by prescription drug benefits. Finally, we look at a sub-population of Canadians with mental illness with regard to their insurance coverage and use of prescription drugs. Our findings suggest that drug coverage within provinces is working for individuals with chronic physical conditions only. The findings herein reaffirm the need for a national strategy, support the notion that prescription drug coverage is important, and raise questions about the role of employers in providing these benefits.
STUDY OBJECTIVE: We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit. METHODS: This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year. RESULTS: Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use. CONCLUSION: ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.
The demographic and health characteristics of metropolitan and nonmetropolitan adolescents are examined based on a nationally representative sample of 15,181 randomly selected adolescents from the 1984 National Health Interview Survey. One third of all adolescents reside in nonmetropolitan areas of the United States. Nonmetropolitan youth differed from their metropolitan counterparts in race, population concentration in the South, poverty status, family composition, education of household head, and marital status. While the health status of metropolitan and nonmetropolitan youth were similar, their patterns of health services utilization and health insurance coverage were not. Nonmetropolitan adolescents made fewer physician visits and were more apt to delay seeking physician care than metropolitan youth. Adolescents in nonmetropolitan areas were also 39 percent more likely to be hospitalized and 30 percent more likely than metropolitan youth to be without any form of health insurance protection. Despite higher rates of poverty among nonmetropolitan adolescents, they were 20 percent less likely to be publicly insured. The delivery and financing implications of these distinct metropolitan and nonmetropolitan demographic and health characteristics are discussed.
Pervasive health disparities continue to exist among racial/ethnic minority groups, but the factors related to these disparities have not been fully elucidated. We undertook this prospective cohort study to determine the independent contributions of socioeconomic status (SES), health behaviors, and health insurance in explaining racial/ethnic disparities in mortality and health declines. Our study period was 1992-1998, and our study population consists of a US nationally representative sample of 6286 non-Hispanic whites (W), 1391 non-Hispanic blacks (B), 405 Hispanics interviewed in English (H/E), and 318 Hispanics interviewed in Spanish (H/S), ages 51-61 in 1992 in the Health and Retirement Study. The main outcome measures were death; major decline in self-reported overall health (SROH); and combined outcome of death or major decline in SROH. Crude mortality rates over the 6-year study period for W, B, H/E and H/S were 5.8%, 10.6%, 5.8%, and 4.4%, respectively. Rates of major decline in SROH were 14.6%, 23.2%, 22.1% and 39.4%, for W, B, H/E and H/S, respectively. Higher mortality rates for B versus W were mostly explained by worse baseline health. For major decline in SROH, education, income, and net worth independently explained more of the disparities for all three minority groups as compared to health behaviors and insurance, reducing the effect for B and H/E to non-significance, while leaving a significant elevated odds ratio for H/S. Without addressing the as-yet undetermined and pernicious effects of lower SES, public health initiatives that promote changing individual health behaviors and increasing rates of insurance coverage among blacks and Hispanics will not eliminate racial/ethnic health disparities.
In two recent papers, [Journal of Health Economics 18(2), 141-152, Journal of Health Economics 18(6), 811-824] Nyman raised some questions about the welfare calculations and conclusions in our earlier paper [Manning and Marquis, Health insurance: the tradeoff between risk pooling and moral hazard, Vol. 15, 1996]. This note discusses the erroneous criticisms in his papers. First, although, we estimated a Marshallian demand curve, our calculations are based on compensating variations that incorporate the gains from risk pooling. Second, our estimates of second best insurance plans indicate that some cost sharing is optimal, in contradiction to his assertion that our results raise questions about the desirability of insurance coverage. The comment also deals with other issues raised by Nyman.
Life expectancy for individuals with cystic fibrosis (CF) has increased dramatically in the last 30 yr, but it is unclear whether the improved survival has applied equally to individuals with different health insurance status. We developed a retrospective inception cohort of all 189 patients with CF born 1/1/55 to 12/31/70 who had at least one hospitalization at a university referral center. The median survival for patients with CF who were without health insurance was 6.1 yr compared with 20.5 yr for those with Medicaid and 20.5 yr for those with private insurance. Using multivariate Cox regression, health insurance and increased socioeconomic status were independently associated with longer survival. The adjusted relative risk of death was greater for the absence of health insurance than for factors previously shown to predict mortality in individuals with CF (female sex and presentation with meconium ileus). In summary, the absence of health insurance was associated with increased mortality rate in children with CF and was a stronger predictor of mortality than variables previously shown to be associated with mortality for CF. If increasing numbers of children with CF lose health insurance coverage, our results suggest that their life expectancy will decrease dramatically.
As pressure mounts to contain Medicaid long term care spending, short-range "quick fixes" must be avoided. Three such false solutions in particular have shortcomings that may actually exacerbate long term care's financial dilemma because they are based on inadequate definitions of the problem. Two of these proposals--legislation to broaden family responsibility toward institutionalized elders on Medicaid and expanded state power to put liens on such elders' real property--err by trying to mandate "caring" and are predicated on a misunderstanding of the "spend-down" problem. The other proposal--to provide tax incentives to family members who care for elders--requires a large administrative apparatus, assumes an elasticity of supply that may not exist, and could disrupt the "gift relationship" on which family exchanges are often based. What is needed is a strategy with short term, intermediate, and long term objectives that move toward an insurance approach. The short term plan should lay the groundwork for intermediate strategy and control costs by changing rate-setting methods and putting limits on facility construction. The intermediate plan should change the problem's definition from one of merely controlling Medicaid long term care expenditures to one of efficiently managing state resources for the elderly through the development of state financing and local delivery systems that target older persons in greatest need. An effective means of doing this is through the creation of social/HMOs, which have five key features: integration of service responsibility and authority; flexibility in organizational design; balanced clientele; pooled prepaid funding; and financial risk for the provider organization. Finally, the long term strategy should transfer much of the long term care financial burden from individuals and state Medicaid agencies to insurance mechanisms. Many individuals would thus avoid impoverishment caused by health care spending and Medicaid would greatly reduce its caseload. Insurance coverage is an appropriate funding mechanism, moreover, in that relatively few persons will ever incur high costs.
To understand local media's role in a community health initiative, a content analysis of 1,709 paragraphs from 173 news articles and editorials was undertaken. The articles were from three local newspapers, one in each of three communities. Analyses focused on article content combined with reflective personal interviews with local campaign directors. Results suggest that local campaign staff can be successful using commercial media to achieve objectives. Surprisingly, most coverage was not about projects with observable and easily identifiable benefits for local residents, but rather partnerships among influential residents engaged in decision-making about such projects. We conclude that the politics of resource distribution is more newsworthy to local journalists than tangible topics like access to health information, insurance coverage, and service provision.
Several chronic diseases are more severe in persons who are Black, of low socioeconomic status (SES), and underinsured. The authors ask if this is true for sarcoidosis. Associations among sarcoidosis disease severity, SES, insurance coverage, and functional limitations were analysed. Back and White sarcoidosis patients (n=110) of a municipal and university hospital sarcoidosis registry were interviewed by telephone. Data on disease severity were abstracted from patient charts. Most patients reported good or excellent health by demographic characteristics. Low SES and no or public insurance were associated with worse health status and more severe dyspnoea. More advanced radiographic stage was associated with lower income, and forced vital capacity impairment with less education. Physical and social activity limitations due to physical and emotional disability were related to no or public insurance and lower income, but not education. Sarcoidosis severity is associated with socioeconomic status and insurance indicators; no or public insurance and low income are associated with functional limitations. Sarcoidosis-associated limitations are substantial, emphasizing the social significance of sarcoidosis. Lack of private insurance may inhibit the use of medical care, contributing to disease severity and impairment.
BACKGROUND: The recently enacted State Children's Health Insurance Program (SCHIP), designed to provide affordable health insurance for uninsured children, was modeled in part on New York State's Child Health Plus (CHPlus), which was implemented in 1991. All SCHIP programs involve voluntary enrollment of eligible children. Little is known about characteristics of children who enroll in these programs. OBJECTIVES: To provide a profile of children enrolled in CHPlus between 1993 and 1994 in the 6-county upstate New York study area, and to estimate the participation rate in CHPlus. Methods. A parent interview was conducted to obtain information about children, 0 to 6.9 years old, who enrolled in CHPlus in the study area. Two school-based surveys and the Current Population Survey were used to estimate health insurance coverage. Enrollment data from New York State's Department of Health, together with estimates of the uninsured, were used to estimate participation rates in CHPlus. RESULTS: Most children enrolled in CHPlus in the study area were white. Although 17% of all children in the study area who were <13 years old and living in families with incomes below 160% of the federal poverty level were black, only 9% of CHPlus-enrolled children were black. Twenty-one percent of enrolled children were uninsured during the entire year before enrollment and 61% of children had a gap in coverage lasting >1 month. Children were generally healthy; only 4% had fair or poor health. Eighty-eight percent of parents of enrolled children had completed high school or a higher level of education. Parents reported that loss of a job was the main reason for loss of prior health insurance for their child. Most families learned about CHPlus from a friend (30%) or from their doctor (26%). The uninsured rate among children in the study area was approximately 4.1%. By 1993, the participation rate in CHPlus was about 36%. CONCLUSION: Blacks were underrepresented in CHPlus. Because the underlying uninsured rate was relatively low and parental education and family income were relatively high, the effects of CHPlus observed in this evaluation may be conservative in comparison to the potential effects of CHPlus for other populations of children. Participation rates during the early years of the program were modest.
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.