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Izguttinov A, Trogdon JG. Can Medicaid be a Solution to the Problem? Underinsurance in Medicaid Expansion Versus Non-Expansion States. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231202640. [PMID: 37776294 PMCID: PMC10542319 DOI: 10.1177/00469580231202640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/18/2023] [Accepted: 09/01/2023] [Indexed: 10/02/2023]
Abstract
The positive effects of Medicaid expansions have been extensively documented in the literature. However, it is not clear whether the reform has had an equally meaningful effect with respect to underinsurance, which is the state of having health insurance yet lacking adequate coverage or facing substantial financial risks upon usage of services. Based on a quasi-experimental difference-in-differences approach, we analyzed the data from a nationally representative sample to estimate the effect of Medicaid expansion on the probability of underinsurance among the non-elderly low-income adult population of the U.S. We found no evidence of significant changes in the likelihood of underinsurance due to Medicaid expansion during the first 4 years after the ACA implementation. However, a supplementary analysis of the longer-term impact (2018-2019) suggests that there might be a time lag between Medicaid expansion and its effect on underinsurance. It is important to realize that expansion of coverage alone may not be sufficient to protect millions of Americans, particularly those with low incomes, from underinsurance. It is, therefore, crucial for policymakers to build legislative frameworks that protect individuals from excessive healthcare expenses and prevent treatment avoidance or delay.
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Affiliation(s)
- Aniyar Izguttinov
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, USA
| | - Justin G. Trogdon
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, USA
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2
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Jones JR, Kogan MD, Ghandour RM, Minkovitz CS. Out-of-Pocket Health Care Expenditures Among United States Children: Parental Perceptions and Past-Year Expenditures, 2016 to 2017. Acad Pediatr 2021; 21:480-487. [PMID: 33221493 DOI: 10.1016/j.acap.2020.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 11/10/2020] [Accepted: 11/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the association between parental perceptions of out-of-pocket (OOP) health care costs for their child and the total amount of OOP health care expenditures for that child during the past year. METHODS We used data from the 2016 and 2017 National Surveys of Children's Health, cross-sectional, parent-reported, and nationally representative surveys of noninstitutionalized US children, ages 0 to 17 years. We conducted bivariate analyses to assess characteristics associated with the amount of OOP expenditures and parental perceptions of these costs. We estimated adjusted prevalence ratios for parental perceptions of OOP costs using logistic regression. RESULTS Based on parent report, nearly two thirds (65.7%) of children incurred some amount of past-year OOP expenditures, with 13.3% of children incurring expenditures of ≥$1000. Parents reported that costs were unreasonable for 35.3% of children with past-year expenditures. The amount of OOP spending was associated with parents' perceptions that costs were unreasonable, with 16.5% of those with $1 to 249 in expenditures reporting unreasonable costs compared to 77.5% of those with >$5,000 in expenditures (P < .05). In adjusted analyses, high OOP expenditures, non-Hispanic white race/ethnicity, lack of health insurance, low household income, parental education levels less than a college degree, and foreign-born nativity status were associated with reports of unreasonable costs (P < .05). CONCLUSIONS This study demonstrates an association between attitudinal and economic measures of health care expenditures for children while demonstrating differences in the perception of costs by measures of family economic vulnerability. Results may inform efforts to assess adequacy of health insurance coverage.
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Affiliation(s)
- Jessica R Jones
- Health Resources and Services Administration, Maternal and Child Health Bureau (JR Jones, MD Kogan, and RM Ghandour), Rockville, Md.
| | - Michael D Kogan
- Health Resources and Services Administration, Maternal and Child Health Bureau (JR Jones, MD Kogan, and RM Ghandour), Rockville, Md
| | - Reem M Ghandour
- Health Resources and Services Administration, Maternal and Child Health Bureau (JR Jones, MD Kogan, and RM Ghandour), Rockville, Md
| | - Cynthia S Minkovitz
- Departments of Population, Family and Reproductive Health and Pediatrics, Johns Hopkins Bloomberg School of Public Health (CS Minkovitz), Baltimore, Md
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3
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Hawks L, Himmelstein DU, Woolhandler S, Bor DH, Gaffney A, McCormick D. Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017. JAMA Intern Med 2020; 180:439-448. [PMID: 31985751 PMCID: PMC6990729 DOI: 10.1001/jamainternmed.2019.6538] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist. OBJECTIVE To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States. DESIGN, SETTING, AND PARTICIPANTS Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services. MAIN OUTCOMES AND MEASURES The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income. RESULTS Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]). CONCLUSIONS AND RELEVANCE Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.
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Affiliation(s)
- Laura Hawks
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - David U Himmelstein
- Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York, New York
| | - Steffie Woolhandler
- Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York, New York
| | - David H Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Adam Gaffney
- Harvard Medical School, Boston, Massachusetts.,Division of Pulmonary and Critical Care, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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4
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Getrich CM, Rapport K, Burdette A, Ortez-Rivera A, Umanzor D. Navigating a fragmented health care landscape: DACA recipients' shifting access to health care. Soc Sci Med 2019; 223:8-15. [PMID: 30685567 DOI: 10.1016/j.socscimed.2019.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/09/2019] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
Deferred Action for Childhood Arrivals (DACA) recipients face an uncertain fate as their future in the United States is being debated. Yet even before the program was introduced in June 2012 and became endangered in September 2017, they encountered challenges in navigating a fragmented health care landscape throughout the United States. This paper focuses on DACA recipients' experiences in accessing health care throughout their lives, both before and after receiving DACA. We conducted semi-structured interviews and questionnaires with 30 DACA recipients living in Maryland between April-December 2016. Participants represented 13 countries of origin and ranged in age between 18 and 28. Results demonstrate that DACA recipients have had punctuated coverage throughout their lives and continue to face constrained access despite temporary gains in status. Health care access is further stratified within their mixed-status families. Participants have also experienced shifts in their health care coverage due to moving between jurisdictions with variable eligibility and changing life circumstances related to family, school, and employment. This article underscores the importance of examining young adult immigrants' access to care over time as they weather changes in the broader policy context and in highly variable contexts of reception nationwide, shaped by state, but also county and city policies and programs. The challenges and gaps in coverage DACA recipients face also underscore the need for both health care and immigration reform.
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Affiliation(s)
- Christina M Getrich
- University of Maryland, College Park, Department of Anthropology, 1111 Woods Halls, 4302 Chapel Lane, College Park, MD, 20742, USA.
| | - Kaelin Rapport
- Northwestern University, Department of Anthropology, 1810 Hinman Avenue, Evanston, IL, 60208, USA.
| | - Alaska Burdette
- University of Maryland, College Park, Department of Anthropology, 1111 Woods Halls, 4302 Chapel Lane, College Park, MD, 20742, USA.
| | - Ana Ortez-Rivera
- University of Maryland, College Park, Department of Anthropology, 1111 Woods Halls, 4302 Chapel Lane, College Park, MD, 20742, USA.
| | - Delmis Umanzor
- University of Maryland, College Park, Department of Anthropology, 1111 Woods Halls, 4302 Chapel Lane, College Park, MD, 20742, USA.
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Kielb ES, Rhyan CN, Lee JA. Comparing Health Care Financial Burden With an Alternative Measure of Unaffordability. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017732960. [PMID: 28975850 PMCID: PMC5798734 DOI: 10.1177/0046958017732960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Health insurance plans with high deductibles increase exposure to health care costs, raising concerns about how the growth in these plans may be impacting both the financial burden of health care expenditures on families and their access to health care. We find that foregoing medical care is common among low-income, privately insured families, occurring at a greater rate than those with higher incomes or Medicare coverage. To better understand the relationship between out-of-pocket (OOP) spending and access, we used the 2011-2014 Medical Expenditure Panel Survey (MEPS) data and a logistic model to analyze the likelihood of avoiding or delaying needed medical care based on health insurance design and other individual and family characteristics. We find that avoiding or delaying medical care is strongly correlated with coverage under a high-deductible health plan, and with depression, poor perceived health, or poverty. However, it is relatively independent of the percent of income spent on OOP costs, making the percent of income spent on OOP costs by itself a poor measure of health care unaffordability. Individuals who spend a small percentage of their income on health care costs may still be extremely burdened by their health plan when financial concerns prevent access to health care. This work emphasizes the importance of insurance design as a predictor of access and the need to expand the definition of financial barriers to care beyond expenditures, particularly for the low-income, privately insured population.
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6
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Bernstein J. Not the Last Word: JoeCare: Free Health Insurance Coverage for All. Clin Orthop Relat Res 2017; 475:1537-1543. [PMID: 28378276 PMCID: PMC5406363 DOI: 10.1007/s11999-017-5341-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/30/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Joseph Bernstein
- 0000 0004 1936 8972grid.25879.31Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104 USA
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7
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Thomson MD, Siminoff LA. Finding medical care for colorectal cancer symptoms: experiences among those facing financial barriers. HEALTH EDUCATION & BEHAVIOR 2015; 42:46-54. [PMID: 25394821 PMCID: PMC4604569 DOI: 10.1177/1090198114557123] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Financial barriers can substantially delay medical care seeking. Using patient narratives provided by 252 colorectal cancer patients, we explored the experience of financial barriers to care seeking. Of the 252 patients interviewed, 84 identified financial barriers as a significant hurdle to obtaining health care for their colorectal cancer symptoms. Using verbatim transcripts of the narratives collected from patients between 2008 and 2010, three themes were identified: insurance status as a barrier (discussed by n = 84; 100% of subsample), finding medical care (discussed by n = 30; 36% of subsample) and, insurance companies as barriers (discussed by n = 7; 8% of subsample). Our analysis revealed that insurance status is more nuanced than the categories insured/uninsured and differentially affects how patients attempt to secure health care. While barriers to medical care for the uninsured have been well documented, the experiences of those who are underinsured are less well understood. To improve outcomes in these patients it is critical to understand how financial barriers to medical care are manifested. Even with anticipated changes of the Affordable Care Act, it remains important to understand how perceived financial barriers may be influencing patient behaviors, particularly those who have limited health care options due to insufficient health insurance coverage.
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8
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Fletcher RA. Keeping up with the Cadillacs: What Health Insurance Disparities, Moral Hazard, and the Cadillac Tax Mean to The Patient Protection and Affordable Care Act. Med Anthropol Q 2014; 30:18-36. [PMID: 25132244 DOI: 10.1111/maq.12120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A major goal of The Patient Protection and Affordable Care Act is to broaden health care access through the extension of insurance coverage. However, little attention has been given to growing disparities in access to health care among the insured, as trends to reduce benefits and increase cost sharing (deductibles, co-pays) reduce affordability and access. Through a political economic perspective that critiques moral hazard, this article draws from ethnographic research with the United Steelworkers (USW) at a steel mill and the Retail, Wholesale and Department Store Union (RWDSU) at a food-processing plant in urban Central Appalachia. In so doing, this article describes difficulties of health care affordability on the eve of reform for differentially insured working families with employer-sponsored health insurance. Additionally, this article argues that the proposed Cadillac tax on high-cost health plans will increase problems with appropriate health care access and medical financial burden for many families.
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Lavelle B, Lorenz FO, Wickrama KAS. What Explains Divorced Women's Poorer Health?: The Mediating Role of Health Insurance and Access to Health Care in a Rural Iowan Sample *. RURAL SOCIOLOGY 2012; 77:601-625. [PMID: 23457418 PMCID: PMC3583357 DOI: 10.1111/j.1549-0831.2012.00091.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The economic restructuring in rural areas in recent decades has been accompanied by rising marital instability. To examine the implications of the increase in divorce for the health of rural women, we examine how marital status predicts adequacy of health insurance coverage and health care access, and whether these factors help to account for the documented association between divorce and later illness. Analyzing longitudinal data from a cohort of over 400 married and recently divorced rural Iowan women, we decompose the total effect of divorce on physical illness a decade later using structural equation modeling. Divorced women are less likely to report adequate health insurance in the years following divorce, inhibiting their access to medical care and threatening their physical health. Full-time employment acts as a buffer against insurance loss for divorced women. The growth of marital instability in rural areas has had significant ramifications for women's health; the decline of adequate health insurance coverage following divorce explains a component of the association between divorced status and poorer long-term health outcomes.
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10
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Herman PM, Rissi JJ, Walsh ME. Health insurance status, medical debt, and their impact on access to care in Arizona. Am J Public Health 2011; 101:1437-43. [PMID: 21680916 PMCID: PMC3134508 DOI: 10.2105/ajph.2010.300080] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2010] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the impact of health insurance status on medical debt among Arizona residents and the impact of both of these factors on access to care. METHODS We estimated logistic regression models for medical debt (problems paying and currently paying medical bills) and access to care (medical care and medications delayed or missed because of cost or lack of insurance). RESULTS Insured status did not predict medical debt after control for health status, income, age, and household characteristics. Insured status (adjusted odds ratio [AOR] = 0.32), problems paying medical bills (AOR = 4.96), and currently paying off medical bills (AOR = 3.04) were all independent predictors of delayed medical care, but only problems paying (AOR = 6.16) and currently paying (AOR = 3.68) medical bills predicted delayed medications. Inconsistent coverage, however, was a strong predictor of problems paying bills, and both of these factors led to delays in medical care and medications. CONCLUSIONS At least in Arizona, health insurance does not protect individuals from medical debt, and medical debt and lack of insurance coverage both predict reduced access to care. These results may represent a troubling message for US health care in general.
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11
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Lavarreda SA, Brown ER, Bolduc CD. Underinsurance in the United States: an interaction of costs to consumers, benefit design, and access to care. Annu Rev Public Health 2011; 32:471-82. [PMID: 21219167 DOI: 10.1146/annurev.publhealth.012809.103655] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Underinsurance is most commonly defined as the state in which people with medical coverage are still exposed to financial risk. We argue that the adequacy of health insurance coverage should also be assessed in terms of the adequacy of specific benefits coverage and access to care. Underinsurance can be understood conceptually as comprising three separate domains: (a) the economic features of health insurance, (b) the benefits covered, and (c) access to health services. The literature provides ample evidence that people who are underinsured have high financial risk and face barriers in access to care similar to those who are completely uninsured. In response to the growing recognition of the problems associated with underinsurance, the Patient Protection and Affordable Care Act of 2010 includes numerous provisions designed to limit costs to consumers, to assure a minimum set of benefits, and to enhance access to care, especially primary care.
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Affiliation(s)
- Shana Alex Lavarreda
- UCLA Center for Health Policy Research, University of California, Los Angeles, 90025, USA.
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12
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Hall MA. Access to care provided by better safety net systems for the uninsured: measuring and conceptualizing adequacy. Med Care Res Rev 2011; 68:441-61. [PMID: 21536602 DOI: 10.1177/1077558710394201] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This descriptive study assesses the access to care provided by five model and diverse safety net programs that enroll uninsured adults in a coordinated system offering primary care, hospital care, prescription drugs, and most specialist services. Physician use by safety net program members was similar to insured groups. However, there was less use of hospitals in the two programs that relied on uncompensated charity care. Considering access measures commonly used in population-based surveys, the uninsured in these five communities fared no better than uninsured elsewhere. However, respondents may consider enrollment in a well-structured safety net program to be equivalent to insurance. If so, population surveys may be least accurate in identifying uninsured people in the very communities that have the best safety net programs. On balance the five safety net systems profiled here meet the needs of low-income uninsured residents at a level that is roughly similar to that for people with insurance.
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Affiliation(s)
- Mark A Hall
- Wake Forest University, Winston-Salem, NC, USA.
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13
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Sultan P, Qadan M, Pushpanathan E, Carvalho B. A practical guide to undertaking out of programme experience in the United States of America. Br J Hosp Med (Lond) 2010; 71:M158-9. [PMID: 20944517 DOI: 10.12968/hmed.2010.71.sup10.78984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P Sultan
- Stanford University School of Medicine, California, CA 94305, USA
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14
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Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM, Singh GK, Strickland BB, van Dyck PC. Underinsurance among children in the United States. N Engl J Med 2010; 363:841-51. [PMID: 20818845 DOI: 10.1056/nejmsa0909994] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent interest in policy regarding children's health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children's needs. METHODS We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children's Health (sample size, 91,642 children) regarding parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home. RESULTS We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage--14.1 million children--were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality. CONCLUSIONS The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)
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Affiliation(s)
- Michael D Kogan
- Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD 20857, USA.
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15
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Tuppin P, Drouin J, Mazza M, Weill A, Ricordeau P, Allemand H. Hospitalization admission rates for low-income subjects with full health insurance coverage in France. Eur J Public Health 2010; 21:560-6. [DOI: 10.1093/eurpub/ckq108] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Smolderen KG, Spertus JA, Nallamothu BK, Krumholz HM, Tang F, Ross JS, Ting HH, Alexander KP, Rathore SS, Chan PS. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA 2010; 303:1392-400. [PMID: 20388895 PMCID: PMC3020978 DOI: 10.1001/jama.2010.409] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Little is known about how health insurance status affects decisions to seek care during emergency medical conditions such as acute myocardial infarction (AMI). OBJECTIVE To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI. DESIGN, SETTING, AND PATIENTS Multicenter, prospective study using a registry of 3721 AMI patients enrolled between April 11, 2005, and December 31, 2008, at 24 US hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews. MAIN OUTCOME MEASURE Prehospital delay times (< or = 2 hours, > 2-6 hours, or > 6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models. RESULTS Of 3721 patients, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (P < .001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21 [95% confidence interval, 1.05-1.41]; P = .01) and with uninsured patients (adjusted odds ratio, 1.38 [95% confidence interval, 1.17-1.63]; P < .001). CONCLUSION Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
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Affiliation(s)
- Kim G. Smolderen
- Center of Research on Psychology in Somatic Diseases, Department of Medical Psychology, Tilburg University, Tilburg, The Netherlands
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
- University of Missouri – Kansas City, MO
| | - Brahmajee K. Nallamothu
- VA Health Services Research and Development Center for Excellence and Department of Medicine, University of Michigan, Medical School, Ann Arbor, MI
| | - Harlan M. Krumholz
- The Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine; the Section of Health Policy and Administration, Department of Epidemiology and Public Health; the Center for Outcomes Research and Evaluation; Yale New Haven Hospital, New Haven, CT
- MD/PhD Program, Yale University School of Medicine, New Haven, CT
| | - Fengming Tang
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| | - Joseph S. Ross
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY
- HSR&D Research Enhancement Award Program and Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
| | - Henry H. Ting
- Division of Cardiovascular Diseases and Mayo Clinic College of Medicine, Rochester, MN
| | - Karen P. Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Saif S. Rathore
- MD/PhD Program, Yale University School of Medicine, New Haven, CT
| | - Paul S. Chan
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
- University of Missouri – Kansas City, MO
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Grosse SD. Sociodemographic Characteristics of Families of Children with Down Syndrome and the Economic Impacts of Child Disability on Families. INTERNATIONAL REVIEW OF RESEARCH IN MENTAL RETARDATION 2010. [DOI: 10.1016/s0074-7750(10)39009-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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Blewett LA. Persistent disparities in access to care across health care systems. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2009; 34:635-647. [PMID: 19633226 DOI: 10.1215/03616878-2009-020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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19
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Blewett LA, Rodin H, Davidson G, Davern M. Measuring adequacy of coverage for the privately insured: new state estimates to monitor trends in health insurance coverage. Med Care Res Rev 2009; 66:167-80. [PMID: 19151260 DOI: 10.1177/1077558708330426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Gruber J, Levy H. The evolution of medical spending risk. THE JOURNAL OF ECONOMIC PERSPECTIVES : A JOURNAL OF THE AMERICAN ECONOMIC ASSOCIATION 2009; 23:25-48. [PMID: 19946978 DOI: 10.1257/jep.23.4.25] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
How has the economic risk of health spending changed over time for U.S. households? We describe trends in aggregate health spending in the United States and how private insurance markets and public insurance programs have changed over time. We then present evidence from Consumer Expenditure Survey microdata on how the distribution of household spending on health—that is, out-of-pocket payments for medical care plus the household's share of health insurance premiums—has changed over time. This distribution has shifted up over time—households spend more on medical care and insurance than they used to—but for the purposes of measuring change in risk, it is not the mean but the dispersion of this distribution that is of interest. We consider two measures of dispersion that serve as proxies for household risk: the standard deviation of the distribution of household health spending and the ratio of the 90th percentile of spending to the median (the so-called “90/50 gap”). We find, surprisingly, that neither has increased despite the rapid rise in aggregate health spending. This conclusion holds true for broad subgroups of the population (for example, the nonelderly as a group) but not for some narrowly-defined subgroups (for example, low-income families with children). We next consider how much risk households should face, from the perspective of economic efficiency. Household risk may not have changed much over the past several decades, but do we have any evidence that this level represents either too much or too little risk? Finally, we discuss implications for public policy—in particular, for current debates over expanding health insurance coverage to the uninsured.
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Affiliation(s)
- Jonathan Gruber
- Massachusetts Institute of Technology and National Bureau of Economic Research, Cambridge, Massachusetts, USA.
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21
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Luthy KE, Peterson NE, Wilkinson J. Cost-Efficient Treatment Options for Uninsured or Underinsured Patients For Five Common Conditions. J Nurse Pract 2008. [DOI: 10.1016/j.nurpra.2008.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Hall JP, Moore JM. Does High-Risk Pool Coverage Meet the Needs of People at Risk for Disability? INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2008; 45:340-52. [DOI: 10.5034/inquiryjrnl_45.03.340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
State high-risk insurance pools serve people denied coverage because of pre-existing conditions. With benefit plans modeled on the individual market, these pools generally require higher out-of-pocket expenditures and provide fewer benefits than employer-sponsored plans, while their beneficiaries have very intensive needs. We profile 416 working adults enrolled in a state high-risk pool and document their health conditions and health care utilization. High-risk pool and federal employee benefits are compared to assess insurance structure and implications for health and disability outcomes.
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23
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Luthy KE, Peterson NE, Wilkinson J. Cost-efficient treatment for uninsured or underinsured patients with hypertension, depression, diabetes mellitus, insomnia, and gastroesophageal reflux. ACTA ACUST UNITED AC 2008; 20:136-43. [DOI: 10.1111/j.1745-7599.2007.00302.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Schoen C, Collins SR, Kriss JL, Doty MM. How Many Are Underinsured? Trends Among U.S. Adults, 2003 And 2007. Health Aff (Millwood) 2008; 27:w298-309. [DOI: 10.1377/hlthaff.27.4.w298] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Cathy Schoen
- Cathy Schoen is senior vice president of the Commonwealth Fund in New York City. Sara Collins is assistant vice president; Jennifer Kriss, program associate; and Michelle Doty, associate director of research
| | - Sara R. Collins
- Cathy Schoen is senior vice president of the Commonwealth Fund in New York City. Sara Collins is assistant vice president; Jennifer Kriss, program associate; and Michelle Doty, associate director of research
| | - Jennifer L. Kriss
- Cathy Schoen is senior vice president of the Commonwealth Fund in New York City. Sara Collins is assistant vice president; Jennifer Kriss, program associate; and Michelle Doty, associate director of research
| | - Michelle M. Doty
- Cathy Schoen is senior vice president of the Commonwealth Fund in New York City. Sara Collins is assistant vice president; Jennifer Kriss, program associate; and Michelle Doty, associate director of research
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25
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Abstract
In a 2002 speech, Mark McClellan, a member of the Council of Economic Advisors at the White House, said that "[I]n the president's vision, all Americans should have access to high-quality and affordable healthcare." However, many healthcare researchers believe that a growing number of Americans are underinsured. Because any characterization of underinsurance will refer to the value judgments of people about what counts as "adequate" and "inadequate" healthcare, the goal of characterizing and measuring the underinsured is difficult to achieve. In this article, I examine the various dimensions of underinsurance, and propose a typology incorporating those dimensions.
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Affiliation(s)
- Andrew Ward
- University of Minnesota, Minneapolis, Minnesota 55455, USA.
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