Access and cost barriers to mental health care, by insurance status, 1999-2010

The cost of mental health services has always been a great barrier to accessing care for people with mental health problems. This article documents changes in insurance coverage and cost for mental health services for people with public insurance, private insurance, and no coverage. In 2009-10 people with mental health problems were more likely to have public insurance and less likely to have private insurance than in 1999-2000. Although access to specialty care remained relatively stable for people with mental illnesses, cost barriers to care increased among the uninsured and the privately insured who had serious mental illnesses. The rise in cost barriers among those with private insurance suggests that the current financing of care in the private insurance market is insufficient to alleviate cost burdens and has implications for reforms under the Affordable Care Act. People with mental health problems who are newly eligible to purchase private insurance under the act might still encounter high cost barriers to accessing care.

Survey of high-risk pool enrollees suggests that targeted transition education and outreach should begin soon

Several provisions of the Affordable Care Act make state and federal high-risk pools unnecessary beginning in January 2014. As a result, thousands of enrollees in those pools will be transferred to Medicaid and the new state and federal insurance exchanges. Our study analyzed new survey data collected from enrollees in the country's oldest and largest state-based high-risk pool, the Minnesota Comprehensive Health Association. We estimate that approximately half of the enrollees in that pool will qualify for Medicaid or premium subsidies in the exchange. More than 60 percent of the enrollees reported being somewhat or very unfamiliar with health care reform and the resulting changes to their current coverage. Their concerns about the expected impact of health reform varied by income, geography, and level of deductible. Targeting education and outreach information to address these concerns will be critical for this population's smooth transition to new coverage.

Monitoring health reform efforts: which state-level data to use?

This study compares estimates of health insurance coverage from the American Community Survey (ACS) to those in twelve state-specific surveys. Uninsurance estimates for the nonelderly are consistently higher in the ACS than in state surveys, as are direct purchase insurance estimates. Estimates for employer-sponsored insurance are similar, but public coverage rates are lower in the ACS. The ACS meets some but not all of the states' data needs; its large sample size and inclusion of all U.S. counties in the sample allow for comparison of insurance coverage within and across states. State-specific surveys provide the flexibility to add policy-relevant questions, including questions needed to examine how health insurance translates into access, use, and affordability of health services.

National and state-specific health insurance disparities for adults in same-sex relationships

OBJECTIVES

We examined national and state-specific disparities in health insurance coverage, specifically employer-sponsored insurance (ESI) coverage, for adults in same-sex relationships.

METHODS

We used data from the American Community Survey to identify adults (aged 25-64 years) in same-sex relationships (n = 31,947), married opposite-sex relationships (n = 3,060,711), and unmarried opposite-sex relationships (n = 259,147). We estimated multinomial logistic regression models and state-specific relative differences in ESI coverage with predictive margins.

RESULTS

Men and women in same-sex relationships were less likely to have ESI than were their married counterparts in opposite-sex relationships. We found ESI disparities among adults in same-sex relationships in every region, but we found the largest ESI gaps for men in the South and for women in the Midwest. ESI disparities were narrower in states that had extended legal same-sex marriage, civil unions, and broad domestic partnerships.

CONCLUSIONS

Men and women in same-sex relationships experience disparities in health insurance coverage across the country, but residing in a state that recognizes legal same-sex marriage, civil unions, or broad domestic partnerships may improve access to ESI for same-sex spouses and domestic partners.

Disparities in health insurance among children with same-sex parents

OBJECTIVES

The objectives of this study were to examine disparities in health insurance coverage for children with same-sex parents and to investigate how statewide policies such as same-sex marriage and second-parent adoptions affect children's private insurance coverage.

METHODS

We used data from the 2008-2010 American Community Survey to identify children (aged 0-17 years) with same-sex parents (n = 5081), married opposite-sex parents (n = 1369789), and unmarried opposite-sex parents (n = 101678). We conducted multinomial logistic regression models to estimate the relationship between family type and type of health insurance coverage for all children and then stratified by each child's state policy environment.

RESULTS

Although 77.5% of children with married opposite-sex parents had private health insurance, only 63.3% of children with dual fathers and 67.5% with dual mothers were covered by private health plans. Children with same-sex parents had fewer odds of private insurance after controlling for demographic characteristics but not to the extent of children with unmarried opposite-sex parents. Differences in private insurance diminished for children with dual mothers after stratifying children in states with legal same-sex marriage or civil unions. Living in a state that allowed second-parent adoptions also predicted narrower disparities in private insurance coverage for children with dual fathers or dual mothers.

CONCLUSIONS

Disparities in private health insurance for children with same-sex parents diminish when they live in states that secure their legal relationship to both parents. This study provides supporting evidence in favor of recent policy statements by the American Academy of Pediatricians endorsing same-sex marriage and second-parent adoptions.

Use of the integrated health interview series: trends in medical provider utilization (1972-2008)

The Integrated Health Interview Series (IHIS) is a public data repository that harmonizes four decades of the National Health Interview Survey (NHIS). The NHIS is the premier source of information on the health of the U.S. population. Since 1957 the survey has collected information on health behaviors, health conditions, and health care access. The long running time series of the NHIS is a powerful tool for health research. However, efforts to fully utilize its time span are obstructed by difficult documentation, unstable variable and coding definitions, and non-ignorable sample re-designs. To overcome these hurdles the IHIS, a freely available and web-accessible resource, provides harmonized NHIS data from 1969-2010. This paper describes the challenges of working with the NHIS and how the IHIS reduces such burdens. To demonstrate one potential use of the IHIS we examine utilization patterns in the U.S. from 1972-2008.

Rescued by the safety net

The recent recession had a significant impact on the nation and Minnesota both in terms of the number of jobs lost and the loss of employer-sponsored health insurance (ESI). In this article, we present national and Minnesota-specific data on the loss of ESI. We also explore how government-sponsored programs provided a safety net that enabled many people with low incomes to retain health insurance coverage, lessening the recession's impact in Minnesota. We conclude with general comments about the role of the safety net in a health care system in which the majority of people have health care coverage through voluntary employer-based programs.

State high-risk pools: an update on the Minnesota Comprehensive Health Association

State health insurance high-risk pools are a key component of the US health care system's safety net, because they provide health insurance to the "uninsurable." In 2007, 34 states had individual high-risk pools, which covered more than 200 000 people at a total cost of $1.8 billion. We examine the experience of the largest and oldest pool in the nation, the Minnesota Comprehensive Health Association, to document key issues facing state high-risk pools in enrollment and financing. We also considered the role and future of high-risk pools in light of national health care finance reform.

Payment reform. The lynchpin of health care reform

The federal Patient Protection and Affordable Care Act that was signed into law last year includes provisions that will improve access to health care for everyone in the United States and extend insurance coverage to some 300 million people who currently do not have it. But insurance reforms and expansion of coverage are only part of the solution to the problems within our health care system.The way health care is paid for is another important element of reform.This article describes the steps we need to take to change the way we pay for health care and efforts that are underway both in the United States and Minnesota to test new payment models.

Counting uninsurance and means-tested coverage in the American community survey: a comparison to the current population survey

OBJECTIVE

To compare health insurance coverage estimates from the American Community Survey (ACS) to the Current Population Survey (CPS-ASEC).

DATA SOURCES/STUDY SETTING

The 2008 ACS and CPS-ASEC, 2009.

STUDY DESIGN

We compare age-specific national rates for all coverage types and state-level rates of uninsurance and means-tested coverage. We assess differences using t-tests and p-values, which are reported at <.05, <.01, and <.001. An F-test determines whether differences significantly varied by state.

PRINCIPAL FINDINGS

Despite substantial design differences, we find only modest differences in coverage estimates between the surveys. National direct purchase and state-level means-tested coverage levels for children show the largest differences.

CONCLUSIONS

We suggest that the ACS is well poised to become a useful tool to health services researchers and policy analysts, but that further study is needed to identify sources of error and to quantify its bias.

American Indian/Alaska Native uninsurance disparities: a comparison of 3 surveys

OBJECTIVES

We examined whether 3 nationally representative data sources produce consistent estimates of disparities and rates of uninsurance among the American Indian/Alaska Native (AIAN) population and to demonstrate how choice of data source impacts study conclusions.

METHODS

We estimated all-year and point-in-time uninsurance rates for AIANs and non-Hispanic Whites younger than 65 years using 3 surveys: Current Population Survey (CPS), National Health Interview Survey (NHIS), and Medical Expenditure Panel Survey (MEPS).

RESULTS

Sociodemographic differences across surveys suggest that national samples produce differing estimates of the AIAN population. AIAN all-year uninsurance rates varied across surveys (3%-23% for children and 18%-35% for adults). Measures of disparity also differed by survey. For all-year uninsurance, the unadjusted rate for AIAN children was 2.9 times higher than the rate for White children with the CPS, but there were no significant disparities with the NHIS or MEPS. Compared with White adults, AIAN adults had unadjusted rate ratios of 2.5 with the CPS and 2.2 with the NHIS or MEPS.

CONCLUSIONS

Different data sources produce substantially different estimates for the same population. Consequently, conclusions about health care disparities may be influenced by the data source used.

Immigrant children's access to health care: differences by global region of birth

We use data from the National Health Interview Survey (2000-2006) to examine the social determinants of health insurance coverage and access to care for immigrant children by 10 global regions of birth. We find dramatic differences in the social and economic characteristics of immigrant children by region of birth. Children from Mexico and Latin America fare worse than immigrant children born in the U.S. with significantly lower incomes and little or no education. These social determinants, along with U.S. public health policies regarding new immigrants, create significant barriers to access to health insurance coverage, and increase delayed or foregone care. Uninsured immigrant children had 6.5 times higher odds of delayed care compared with insured immigrant children.

Improving geriatric transitional care through inter-professional care teams

OBJECTIVES

The aim of this study was to examine the impact of the use of an inter-professional care team on patient length of stay and payer charges in a geriatric transitional care unit.

METHODS

An analysis of de-identified administrative records for transitional care patients for the 12-month period (2003-2004) cared for by the inter-professional team (n = 163) and cared for by traditional single provider care model (n = 176) was carried out. We conducted logistic regression on length of stay and charges controlling for patient demographics and acuity levels.

RESULTS

The inter-professional care team patients had significantly shorter lengths of stay, fewer patient days and lower total charges. Patient diagnosis and acuity were similar across groups.

CONCLUSION

This study provides empirical evidence of the impact of an inter-professional care model in providing cost-effective transitional care in a nursing home setting. Evidence of shorter lengths of stay, shorter patient days and lower charges suggests benefit in the development and financing of inter-professional care teams for transitional care services.

The importance of geographic data aggregation in assessing disparities in American Indian prenatal care

OBJECTIVES

We sought to determine whether aggregate national data for American Indians/Alaska Natives (AIANs) mask geographic variation and substantial subnational disparities in prenatal care utilization.

METHODS

We used data for US births from 1995 to 1997 and from 2000 to 2002 to examine prenatal care utilization among AIAN and non-Hispanic White mothers. The indicators we studied were late entry into prenatal care and inadequate utilization of prenatal care. We calculated rates and disparities for each indicator at the national, regional, and state levels, and we examined whether estimates for regions and states differed significantly from national estimates. We then estimated state-specific changes in prevalence rates and disparity rates over time.

RESULTS

Prenatal care utilization varied by region and state for AIANs and non-Hispanic Whites. In the 12 states with the largest AIAN birth populations, disparities varied dramatically. In addition, some states demonstrated substantial reductions in disparities over time, and other states showed significant increases in disparities.

CONCLUSIONS

Substantive conclusions about AIAN health care disparities should be geographically specific, and conclusions drawn at the national level may be unsuitable for policymaking and intervention at state and local levels. Efforts to accommodate the geographically specific data needs of AIAN health researchers and others interested in state-level comparisons are warranted.

Health care coverage and the health care industry

OBJECTIVES

We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category.

METHODS

We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype.

RESULTS

Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI]=2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI=3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR]=1.5; 95% CI=1.0, 2.4).

CONCLUSIONS

Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern.

Measuring adequacy of coverage for the privately insured: new state estimates to monitor trends in health insurance coverage

The privately insured are assuming a greater share of the costs of their health care, yet little is known about changes in out-of-pocket spending at the state level. The central problem is that national surveys with the relevant data are not designed to generate state-level estimates. The study addresses this shortcoming by using a two-sample modeling approach to estimate state-level measures of out-of-pocket spending relative to income for privately insured adults and children. National data from the Medical Expenditure Panel Survey-Household Component and state representative data from the Current Population Survey are used. Variation in out-of-pocket spending over time and across states is shown, highlighting concern about the adequacy of coverage for 2.9% of privately insured children and 7.8% of privately insured adults. Out-of-pocket spending relative to income is an important indicator of access to care and should be monitored at the state level.

Persistent disparities in health insurance coverage: Hispanic children, 1996 to 2005

OBJECTIVE

To identify how health insurance coverage trends changed for Hispanic children between 1996 and 2005.

METHODS

Data from the Current Population Survey Annual Social and Economic Supplement were analyzed to determine health insurance coverage rates for Hispanic children and logistic regression was used to determine the role of race/ethnicity on health insurance status, adjusting for citizenship status, child characteristics, migration status, and geography.

RESULTS

The proportion of uninsured Hispanic children decreased significantly. However, the increased likelihood of a Hispanic child being uninsured relative to non-Hispanic White children did not change during this period.

CONCLUSIONS

Expansions in public health insurance programs between 1996 and 2005 increased health insurance coverage for Hispanic children but disparities between Hispanic and non-Hispanic White children persist.

The American Community Survey and health insurance coverage estimates: possibilities and challenges for health policy researchers

OBJECTIVE

To introduce the American Community Survey (ACS) and its measure of health insurance coverage to researchers and policy makers.

DATA SOURCES/STUDY SETTING

We compare the survey designs for the ACS and Current Population Survey (CPS) that measure insurance coverage.

STUDY DESIGN

We describe the ACS and how it will be useful to health policy researchers.

PRINCIPAL FINDINGS

Relative to the CPS, the ACS will provide more precise state and substate estimates of health insurance coverage at a point-in-time. Yet the ACS lacks the historical data and detailed state-specific coverage categories seen in the CPS.

CONCLUSIONS

The ACS will be a critical new resource for researchers. To use the new data to the best advantage, careful research will be needed to understand its strengths and weaknesses.

Four decades of population health data: the integrated health interview series as an epidemiologic resource

The National Health Interview Survey (NHIS) is a primary source of information on the changing health of the US population over the past 4 decades. The full potential of NHIS data for analyzing long-term change, however, has rarely been exploited. Time series analysis is complicated by several factors: large numbers of data files and voluminous documentation; complexity of file structures; and changing sample designs, questionnaires, and variable-coding schemes. We describe a major data integration project that will simplify cross-temporal analysis of population health data available in the NHIS. The Integrated Health Interview Series (IHIS) is a Web-based system that provides an integrated set of data and documentation based on the NHIS public use files from 1969 to the present. The Integrated Health Interview Series enhances the value of NHIS data for researchers by allowing them to make consistent comparisons across 4 decades of dramatic changes in health status, health behavior, and healthcare.

Local access to care programs (LACPs): new developments in the access to care for the uninsured

CONTEXT

New, locally based health care access programs are emerging in response to the growing number of uninsured, providing an alternative to health insurance and traditional safety net providers. Although these programs have been largely overlooked in health services research and health policy, they are becoming an important local supplement to the historically overburdened safety net.

METHODS

This article is based on a literature review, Internet search, and key actor interviews to document programs in the United States, using a typology to classify the programs and document key characteristics.

FINDINGS

Local access to care programs (LACPs) fall outside traditional private and publicly subsidized insurance programs. They have a formal enrollment process, eligibility determination, and enrollment fees that give enrollees access to a network of providers that have agreed to offer free or reduced-price health care services. The forty-seven LACPs documented in this article were categorized into four general models: three-share programs, national-provider networks, county-based indigent care, and local provider-based programs.

CONCLUSIONS

New, locally based health access programs are being developed to meet the health care needs of the growing number of uninsured adults. These programs offer an alternative to traditional health insurance and build on the tradition of county-based care for the indigent. It is important that these locally based, alternative paths to health care services be documented and monitored, as the number of uninsured adults is continuing to grow and these programs are becoming a larger component of the U.S. health care safety net.

Access to health care and voting behavior in the United States

This study examines the relationship between difficulties accessing health care and voting behavior, in order to assess the possible impact that increasing constraints on access to care will have on future voting behavior. Using data from the American National Election Study we found that the proportion of people with difficulty accessing care increased significantly from 27% in 2000 to 35% in 2004. A larger proportion of those with difficulties in accessing care voted in 2004 than in 2000 and their preferences also changed to more heavily favor the Democratic candidate. If the number of those experiencing difficulties accessing care continues to grow, access to care could become a more salient campaign issue. In 2004, Democratic candidates were favored by this group, which is likely to be a constituency that both parties will try to capture in future elections.

When a usual source of care and usual provider matter: adult prevention and screening services

OBJECTIVE

To examine whether the usual source of preventive care, (having a usual place for care only or the combination of a usual place and provider compared with no usual source of preventive care) is associated with adults receiving recommended screening and prevention services.

DESIGN

Using cross-sectional survey data for 24,138 adults (ages 18-64) from the 1999 National Health Interview Survey (NHIS), we estimated adjusted odds ratios using separate logistic regression models for receipt of five preventive services: influenza vaccine, Pap smear, mammogram, clinical breast exam, and prostate specific antigen.

RESULTS

Having both a usual place and a usual provider was consistently associated with increased odds for receiving preventive care/screening services compared to having a place only or neither. Adults ages 50-64 with a usual place/provider had 2.8 times greater odds of receiving a past year flu shot compared with those who had neither. Men ages 50-64 with a usual place/provider had nearly 10 times higher odds of receiving a PSA test compared with men who had neither. Having a usual place/provider compared with having neither was associated with 3.9 times higher odds of clinical breast exam among women ages 20-64, 4.1 times higher odds of Pap testing among women ages 21-64, and 4.8 times higher odds of mammogram among women ages 40-64.

CONCLUSIONS

Having both a usual place and usual provider is a key variable in determining whether adults receive recommended screening and prevention services and should be considered a fundamental component of any medical home model for adults.