Insurance and the U.S. health care system

Is health insurance enough? A usual source of care may be more important to ensure a child receives preventive health counseling

Despite the promise of expanded health insurance coverage for children in the United States, a usual source of care (USC) may have a bigger impact on a child's receipt of preventive health counseling. We examined the effects of insurance versus USC on receipt of education and counseling regarding prevention of childhood injuries and disease. We conducted secondary analyses of 2002-2006 data from a nationally-representative sample of child participants (≤17 years) in the Medical Expenditure Panel Survey (n = 49,947). Children with both insurance and a USC had the lowest rates of missed counseling, and children with neither one had the highest rates. Children with only insurance were more likely than those with only a USC to have never received preventive health counseling from a health care provider regarding healthy eating (aRR 1.21, 95% CI 1.12-1.31); regular exercise (aRR 1.06, 95% CI 1.01-1.12), use of car safety devices (aRR 1.10, 95% CI 1.03-1.17), use of bicycle helmets (aRR 1.11, 95% CI 1.05-1.18), and risks of second hand smoke exposure (aRR 1.12, 95% CI 1.04-1.20). A USC may play an equally or more important role than insurance in improving access to health education and counseling for children. To better meet preventive counseling needs of children, a robust primary care workforce and improved delivery of care in medical homes must accompany expansions in insurance coverage.

Comparing types of health insurance for children: a public option versus a private option

BACKGROUND

Many states have expanded public health insurance programs for children, and further expansions were proposed in recent national reform initiatives; yet the expansion of public insurance plans and the inclusion of a public option in state insurance exchange programs sparked controversies and raised new questions with regard to the quality and adequacy of various insurance types.

OBJECTIVES

We aimed to examine the comparative effectiveness of public versus private coverage on parental-reported children's access to health care in low-income and middle-income families. METHODS/PARTICIPANTS/MEASURES: We conducted secondary data analyses of the nationally representative Medical Expenditure Panel Survey, pooling years 2002 to 2006. We assessed univariate and multivariate associations between child's full-year insurance type and parental-reported unmet health care and preventive counseling needs among children in low-income (n=28,338) and middle-income families (n=13,160).

RESULTS

Among children in families earning <200% of the federal poverty level, those with public insurance were significantly less likely to have no usual source of care compared with privately insured children (adjusted relative risk, 0.79; 95% confidence interval, 0.63-0.99). This was the only significant difference in 50 logistic regression models comparing unmet health care and preventive counseling needs among low-income and middle-income children with public versus private coverage.

CONCLUSIONS

The striking similarities in reported rates of unmet needs among children with public versus private coverage in both low-income and middle-income groups suggest that a public children's insurance option may be equivalent to a private option in guaranteeing access to necessary health care services for all children.

The case for synergy between a usual source of care and health insurance coverage

BACKGROUND

In 2010, the United States (US) passed health insurance reforms aimed at expanding coverage to the uninsured. Yet, disparities persist in access to health care services, even among the insured.

OBJECTIVE

To examine the separate and combined association between having health insurance and/or a usual source of care (USC) and self-reported receipt of health care services.

DESIGN/SETTING

Two-tailed, chi-square analyses and logistic regression models were used to analyze nationally representative pooled 2002-2007 data from the Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

US adults (≥18 years of age) in the MEPS population who had at least one health care visit and who needed any care, tests, or treatment in the past year (n = 62,067).

MAIN OUTCOME MEASURES

We assessed the likelihood of an adult reporting unmet medical needs; unmet prescription needs; a problem getting care, tests, or treatment; and delayed care based on whether each individual had health insurance, a USC, both, or neither one.

KEY RESULTS

Among adults who reported a doctor visit and a need for services in the past year, having both health insurance and a USC was associated with the lowest percentage of unmet medical needs, problems and delays in getting care while having neither one was associated with the highest unmet medical needs, problems and delays in care. After adjusting for potentially confounding covariates (age, race, ethnicity, employment, geographic residence, education, household income as a percent of federal poverty level, health status, and marital status), compared with insured adults who also had a USC, insured adults without a USC were more likely to have problems getting care, tests or treatment (adjusted relative risk [aRR] 1.27; 95% confidence interval [CI] 1.18-1.37); and also had a higher likelihood of experiencing a delay in urgent care (aRR 1.12; 95% CI 1.05-1.20).

CONCLUSIONS

Amidst ongoing health care reform, these findings suggest the important role that both health insurance coverage and a usual source of care may play in facilitating individuals' access to care.

Comparing type of health insurance among low-income children: a mixed-methods study from Oregon

We employed a mixed-methods study of primary data from a statewide household survey and in-person interviews with parents to examine-quantitatively and qualitatively-whether low-income children experienced differences between public and private insurance coverage types. We carried out 24 in-depth interviews with a subsample of respondents to Oregon's 2005 Children's Access to Healthcare Study (CAHS), analyzed using a standard iterative process and immersion/crystallization cycles. Qualitative findings guided quantitative analyses of CAHS data that assessed associations between insurance type and parental-reported unmet children's health care needs. Interviewees uniformly reported that stable health insurance was important, but there was no consensus regarding which type was superior. Quantitatively, there were only a few significant differences. Cross-sectionally, compared with private coverage, public coverage was associated with higher odds of unmet specialty care needs (odds ratio [OR] 3.54; 95% confidence interval [CI] 1.52-8.24). Comparing full-year coverage patterns, those with public coverage had lower odds of unmet prescription needs (OR 0.60, 95% CI 0.36-0.99) and unmet mental health counseling needs (OR 0.24, 95% CI 0.10-0.63), compared with privately covered children. Low-income Oregon parents reported few differences in their child's experience with private versus public coverage.

Health disadvantage in US adults aged 50 to 74 years: a comparison of the health of rich and poor Americans with that of Europeans

OBJECTIVES

We compared the health of older US, English, and other European adults, stratified by wealth.

METHODS

Representative samples of adults aged 50 to 74 years were interviewed in 2004 in 10 European countries (n = 17,481), England (n = 6527), and the United States (n = 9940). We calculated prevalence rates of 6 chronic diseases and functional limitations.

RESULTS

American adults reported worse health than did English or European adults. Eighteen percent of Americans reported heart disease, compared with 12% of English and 11% of Europeans. At all wealth levels, Americans were less healthy than were Europeans, but differences were more marked among the poor. Health disparities by wealth were significantly smaller in Europe than in the United States and England. Odds ratios of heart disease in a comparison of the top and bottom wealth tertiles were 1.94 (95% confidence interval [CI] = 1.69, 2.24) in the United States, 2.13 (95% CI = 1.73, 2.62) in England, and 1.38 (95% CI = 1.23, 1.56) in Europe. Smoking, obesity, physical activity levels, and alcohol consumption explained a fraction of health variations.

CONCLUSIONS

American adults are less healthy than Europeans at all wealth levels. The poorest Americans experience the greatest disadvantage relative to Europeans.

A usual source of care: supplement or substitute for health insurance among low-income children?

OBJECTIVES

To examine the separate and combined effects of having health insurance and a usual source of care (USC) on access to healthcare for low-income children and to determine if one or the other is superior in ensuring better access to necessary services.

METHODS

We conducted cross-sectional, multivariable analyses of data from a mail-return survey of Oregon's food stamp program. Results from 2681 completed surveys were weighted back to a population of 84,087 families with adjustments for oversampling techniques and nonresponse.

RESULTS

Among low-income Oregon children, those with health insurance and a USC reported the best access to healthcare. In multivariable comparisons to this reference group, insured children without a USC had higher rates of unmet medical need [odds ratio (OR) = 2.18; 95% confidence interval (CI): 1.27-3.73]; no doctor visits in 12 months (OR = 6.77; 95% CI: 3.80-12.06); and problems obtaining specialty care (OR = 4.12; 95% CI: 1.59-10.68). Similarly, having a USC but not health insurance was associated with an even higher likelihood of unmet medical needs (OR = 4.33; 95% CI: 2.85-6.57); as well as unmet prescription needs (OR = 2.64, 95% CI: 1.77-3.94), and problems obtaining dental care (OR = 4.83; 95% CI: 3.31-7.06).

CONCLUSIONS

Incremental policy solutions are being proposed that focus on either health insurance coverage for children or expanded access to primary care. However, neither approach displaces the need for the other. The effects of a USC and health insurance, together, are additive predictors of the likelihood that children have optimal access to necessary healthcare services.

Disparities in participation in cancer clinical trials in the United States : a symptom of a healthcare system in crisis

Disparities in minorities' representation in cancer clinical trials have been shown only in adult populations, which suggest that the main causes of these disparities relate to health system-based barriers, including issues of poverty (lack of insurance), poor access to trials, and an inadequate number of clinical trials. Initiatives that increase the participation of community physicians in cancer clinical research trials and increase low socioeconomic status patients' access to cancer trials will likely ameliorate this problem.

Insurance + access not equal to health care: typology of barriers to health care access for low-income families

PURPOSE

Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.

METHODS

A mixed methods analysis was undertaken using 722 responses to an open-ended question on a health care access survey instrument that asked low-income Oregon families, "Is there anything else you would like to tell us?" Themes were identified using immersion/crystallization techniques. Pertinent demographic attributes were used to conduct matrix coded queries.

RESULTS

Families reported 3 major barriers: lack of insurance coverage, poor access to services, and unaffordable costs. Disproportionate reporting of these themes was most notable based on insurance status. A higher percentage of uninsured parents (87%) reported experiencing difficulties obtaining insurance coverage compared with 40% of those with insurance. Few of the uninsured expressed concerns about access to services or health care costs (19%). Access concerns were the most common among publicly insured families, and costs were more often mentioned by families with private insurance. Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families.

CONCLUSIONS

Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere.

Disruptions in insurance coverage: patterns and relationship to health care access, unmet need, and utilization before enrollment in the State Children's Health Insurance Program

BACKGROUND

The numbers and types of disruptions in insurance that children experience and the effects of these disruptions on health care measures have not been well characterized.

OBJECTIVES

Our goals were to (1) describe the number and patterns of insurance disruptions within a population of children newly enrolling into the State Children's Health Insurance Program and (2) assess the relationship among insurance disruptions and sociodemographic characteristics of these children and their families to specific measures of access to care, unmet need, and health care utilization during the year before enrollment.

METHODS

We conducted telephone interviews in families with children newly enrolling in the State Children's Health Insurance Program. Families reported on measures for each of the 12 months preceding enrollment. They were grouped by number of insurance disruptions in the year before enrollment: continuously uninsured, > or = 2 disruptions, 1 disruption, or continuously insured.

RESULTS

Of 920 families contacted, 739 (80%) completed the interview and 710 had useable data. Thirty-five percent reported being continuously uninsured, 42% were intermittently insured (> or = 2 disruptions: 28%; 1 disruption: 14%), and 23% were continuously insured during the previous year. The most common patterns of change were between privately insured and uninsured (49%) and Medicaid and uninsured (40%). The continuously uninsured were more likely to be Hispanic and older in age. Multivariate modeling confirmed a gradient between greater insurance disruption and less access to care, less utilization, and greater unmet medical need. Using the continuously uninsured as a reference group, the adjusted odds ratio for having a medical home varied from 2.5 for those with > or = 2 disruptions to 4.5 for the continuously insured and from 1.9 to 3.2, respectively, for using any regular/routine care. The odds ratio for unmet need for a prescription medication was 0.9 for > or = 2 disruptions and 0.5 for those with continuous insurance coverage.

CONCLUSIONS

There was significant disruption in insurance coverage in the year before State Children's Health Insurance Program enrollment. Most of these disruptions took the form of children previously enrolled in either Medicaid or private insurance becoming uninsured. Increasing numbers of disruptions were associated with less routine care and greater unmet medical need. These findings suggest that disruptions in insurance coverage for children should be minimized with the adoption of policies regarding continuous eligibility criteria for Medicaid and streamlining transitions between Medicaid, the State Children's Health Insurance Program, and private insurance.

Being uninsured: impact on children's healthcare and health

PURPOSE OF REVIEW

There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children.

RECENT FINDINGS

With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs.

SUMMARY

Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.