No insurance, public insurance, and private insurance: do these options contribute to differences in general health?

The prevalence of health problems and their association with physical activity in caregivers of children with disabilities: 2018 National Health Interview Survey

BACKGROUND

Caregivers of children with disabilities often experience poor health. One way for caregivers to promote their own health may be to participate in physical activity (PA).

AIMS

The purpose of this study was to examine the association between PA and psychological and physical health problems in caregivers of children with disabilities.

METHODS

The 2018 National Health Interview Survey (NHIS) data were used, and 890 household representatives were identified as caregivers of children with disabilities. Based on the national PA guidelines, caregivers were classified into three groups: inactive (IA), aerobically active (AA), and aerobically and muscularly active (AMA).

RESULTS

Multivariable logistic regression indicated that the AMA group had a lower likelihood of reporting depression compared to the IA group (OR: 0.73 [95% confidence interval: 0.54, 0.98]). The AMA group also had a lower likelihood of reporting back pain and obesity compared to the IA group (OR:0.69 [95% confidence interval: 0.56, 0.84] and OR:0.63 [95% confidence interval: 0.52, 0.76], respectively).

CONCLUSIONS

The results of the current study suggest that caregivers of children with disabilities may benefit from PA, especially from the combination of aerobic and muscle-strengthening PA.

Multigroup Path Analysis of the Influence of Healthcare Quality, by Different Health Insurance Types

EXECUTIVE SUMMARY

Winds of change have been blowing in the U.S. healthcare system since passage of the Affordable Care Act. Examining differences between individuals covered by different types of insurance is essential if healthcare executives are to develop new strategies in response to the emerging health insurance market. In this study, we used multigroup path analysis models to examine the moderating effects of health insurance on direct and indirect associations with general health status, satisfaction with received care, financial burden, and perceived value of the healthcare system. Data were obtained from the 2012 Medical Expenditure Panel Survey and analyzed according to the types of insurance: private, public, and military. With the satisfactory fit of the model (χ = 2,532.644, df = 96, p < .001; normed fit index = 0.943; incremental fit index = 0.945; comparative fit index = 0.957; root mean squared error of approximation = 0.044), higher healthcare quality was positively associated with better health status, greater satisfaction, and greater perceived value of the healthcare system in the three insurance groups. In addition, although all direct paths between health service quality and financial burden were not statistically significant, indirect effects were significant in all models through health status. Being married and earning higher incomes were also found to be strong predictors of better health status and health service quality. Efforts to improve the quality of health services are needed, which could contribute to a reduction in health disparities among insurance beneficiaries and result in less healthcare spending.

The Influence of Medical Insurance on Patient Access to Orthopaedic Surgery Sports Medicine Appointments Under the Affordable Care Act

Background:

The goal of the Patient Protection and Affordable Care Act (PPACA) was to expand patient access to health care. Since the rollout of the PPACA, Medicaid patients have demonstrated difficulty obtaining appointments in some specialty care settings.

Purpose:

To assess the effect of insurance type (Medicaid and private) on patient access to orthopaedic surgery sports medicine specialists for a semiurgent evaluation of a likely operative bucket-handle meniscus tear. The study was designed to determine whether disparities in access exist since the PPACA rollout.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

The design was to call 180 orthopaedic surgery sports medicine specialists in 6 representative states (California, Ohio, New York, Florida, Texas, and North Carolina) between June 2015 and December 2015. An appointment was requested for the caller’s fictitious 25-year-old-brother who had suffered a bucket-handle meniscus tear. Each office was called twice to assess the ease of obtaining an appointment: once for patients with Medicaid and once for patients with private insurance. For each call, data pertaining to whether an appointment was given, wait times, and barriers to receiving an appointment were recorded.

Results:

A total of 177 surgeons were called within the study period. Overall, 27.1% of offices scheduled an appointment for a patient with Medicaid, compared with 91.2% (P < .0001) for a patient with private insurance. Medicaid patients were significantly more likely to be denied an appointment due to lack of referral compared with private patients (40.2% vs 3.7%, P < .0001), and Medicaid patients were more likely to experience longer wait times for an appointment (15 vs 12 days, P < .029). No significant differences were found in patients’ access to orthopaedic surgery sports medicine specialists between Medicaid-expanded and -nonexpanded states. Medicaid reimbursement for knee arthroscopy with meniscus repair was not significantly correlated with appointment success rate or patient waiting periods.

Conclusion:

Despite the passage of the PPACA, patients with Medicaid have reduced access to care. In addition, patients with Medicaid confront more barriers to receiving appointments than patients with private insurance and wait longer for an appointment.

Citalopram amplifies the influence of living conditions on mood in depressed patients enrolled in the STAR*D study

Selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed antidepressant drugs, have a variable and incomplete efficacy. In order to better understand SSRI action, we explored the hypothesis that SSRIs do not affect mood per se but amplify the influence of the living conditions on mood. To this aim, we exploited the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) data set, selected a subpopulation of 591 patients with an overlapping clinical history and analyzed treatment outcome according to dosage -20 or 40 mg per day of citalopram. We found that sociodemographic characteristics affected treatment response in the same direction in the two dose groups, but these effects reached statistical significance only in the 40 mg per day dose group. In the latter, higher improvement rate was associated with having a working employment status (P=0.0219), longer education (P=0.0053), high income (P=0.01) or a private insurance (P=0.0031), and the higher remission rate was associated with having a working employment status (P=0.0326) or longer education (P=0.0484). Moreover, the magnitude of the effect of the sociodemographic characteristics on mood, measured as the percent of patients showing a positive outcome when exposed to favorable living conditions, was much greater-up to 37-fold-in the 40 compared to the 20 mg per day dose group. Overall, our results indicate that citalopram amplifies the influence of the living conditions on mood in a dose-dependent manner. These findings provide a potential explanation for the variable efficacy of SSRIs and might lead to the development of personalized strategies aimed at enhancing their efficacy.

Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act

BACKGROUND

The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty.

METHODS

We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral.

RESULTS

Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period.

CONCLUSION

Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments.

LEVEL OF EVIDENCE

Level II, prognostic study.

The Effect of Insurance Type on Patient Access to Carpal Tunnel Release Under the Affordable Care Act

PURPOSE

To assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to hand surgeons for carpal tunnel syndrome (CTS).

METHODS

The research team called 240 hand surgeons in 8 states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for her fictitious mother to be evaluated for CTS and possible surgical management through carpal tunnel release (CTR). Each office was called 3 times to assess the responses for Medicaid, Medicare, or Blue Cross Blue Shield. From each call, we recorded whether an appointment was given and whether there were barriers to an appointment, such as the need for a referral.

RESULTS

Twenty percent of offices scheduled an appointment for a patient with Medicaid, compared with 89% for Medicare and 97% for Blue Cross Blue Shield. Patients with Medicaid had an easier time scheduling appointments (28% vs 13%) and experienced fewer requests for referrals (25% vs 67%) in states with expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement for CTR was significantly correlated with the incidence of successful appointments. Although the difference in Medicaid and Medicare reimbursements for CTR was small, the appointment success incidence for Medicare was approximately 5 times higher.

CONCLUSIONS

Despite the passage of the Affordable Care Act, patients with Medicaid have reduced access to surgical care for CTS and more complex barriers to receiving an appointment. Although Medicaid was accepted at a higher rate in states with expanded Medicaid eligibility, a more robust strategy for increasing access to care may be helpful for patients with Medicaid.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Predicting cost of care using self-reported health status data

Background

Methods

Results

Discussion

Conclusions

The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act

This study evaluated access to knee arthroplasty and revision in 8 geographically representative states. Patients with Medicaid were significantly less likely to receive an appointment compared to patients with Medicare or BlueCross. However, patients with Medicaid had increased success at making an appointment in states with expanded Medicaid eligibility (37.7% vs 22.8%, P=0.011 for replacement, 42.6% vs 26.9%, P=0.091 for revision), although they experienced longer waiting periods (31.5 days vs 21.1 days, P=0.054 for replacement, 45.5 days vs 22.5 days, P=0.06 for revision). Higher Medicaid reimbursement also had a direct correlation with appointment success rate for Medicaid patients (OR=1.232, P=0.001 for replacement, OR=1.314, P=0.014 for revision).

Health insurance and chronic conditions in low-income urban whites

Little is known about how health insurance contributes to the prevalence of chronic disease in the overlooked population of low-income urban whites. This study uses cross-sectional data on 491 low-income urban non-elderly non-Hispanic whites from the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB) study to examine the relationship between insurance status and chronic conditions (defined as participant report of ever being told by a doctor they had hypertension, diabetes, stroke, heart attack, anxiety or depression, asthma or emphysema, or cancer). In this sample, 45.8 % were uninsured, 28.3 % were publicly insured, and 25.9 % had private insurance. Insured participants had similar odds of having any chronic condition (odds ratios (OR) 1.06; 95 % confidence intervals (CI) 0.70-1.62) compared to uninsured participants. However, those who had public insurance had a higher odds of reporting any chronic condition compared to the privately insured (OR 2.29; 95 % CI 1.21-4.35). In low-income urban areas, the health of whites is not often considered. However, this is a significant population whose reported prevalence of chronic conditions has implications for the Medicaid expansion and the implementation of health insurance exchanges.

Access to arthroplasty in South Florida

Our objective was to compare the availability of hip and knee arthroplasty to an adult insured by Medicaid and by private insurance. All orthopedic surgeons' offices in a South Florida county were contacted by telephone and presented with a hypothetical patient that needed either a hip or a knee arthroplasty for end stage arthritis. Two scenarios were presented. The hypothetical patient was presented as either having private insurance or Medicaid. 14.3% of all offices contacted offered an appointment to patients with Medicaid coverage for hip and knee arthroplasty, respectively. All offices offered an appointment to patients with private insurance. The mean time until appointment was longer for patients with Medicaid when compared with private insurance. Adults insured with Medicaid currently have limited access to total joint arthroplasty within the studied community.

An Examination of the Relationship between Neighborhood Income Inequality, Social Resources, and Obesity in Los Angeles County

Purpose.

This study examines whether local income inequality is associated with an increased likelihood of obesity among Los Angeles County residents and whether collective efficacy mediates the relationship.

Design.

A cross-sectional study of 2875 adults in 65 neighborhoods that took part in wave 1 of the Los Angeles Family and Neighborhood Survey in 2000-2001. Neighborhood measures are taken from the Los Angeles Neighborhood Services and Characteristics Database and decennial census.

Measures.

Obesity is defined as a body mass index over 30. Income inequality is operationalized with the Gini coefficient. Collective efficacy is a neighborhood-level measure comprised of aggregated responses to items that capture trust, cohesion, and the willingness to intervene for the common good among residents. Controls are included at the individual level for demographics and health characteristics, and at the neighborhood level for median household income.

Analysis.

Logistic regression models of individuals within neighborhoods.

Results.

When neighborhood economic well-being is controlled, income inequality is associated with a significant reduction in the likelihood of obesity while also controlling for individual demographic and health-related characteristics. Collective efficacy exerts an independent and beneficial effect but does not mediate the relationship between inequality and obesity.

Conclusion.

Neighborhood social resources and economic heterogeneity are associated with a lower likelihood of obesity. It may be that economically heterogeneous neighborhoods, perhaps especially in Los Angeles County, contain characteristics that promote health.

Exceptions to the Rule: Exceptional Health Among the Disadvantaged

Countless studies show that socioeconomic status (SES) is strongly related to morbidity and mortality. However, few studies consider the substantial variability in health within socioeconomic strata. In this article, the authors examine the incompatibility between stratification-based theories of health inequality and empirical patterns of exceptional health among the socially disadvantaged. Using panel data from the Health and Retirement Survey (1992-2008), the authors test the mediating and moderating effects of various predictors of exceptional health (no chronic diseases or physical limitations) for middle-aged and older adults with and without a high school education. Results suggest that a combination of demographic characteristics, family and religious factors, socioeconomic resources, health behaviors, psychological makeup, and biological attributes play differing roles in protecting the health of disadvantaged men and women. The findings underscore the complex associations among SES, protective mechanisms, and health and offer new insight into how disadvantaged adults defy their odds of poor health.

Legalism, countertransference, and clinical moral perception

This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician-patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated.

Communication choices of the uninsured: implications for health marketing

According to published scholarship on health services usage, an increasing number of Americans do not have health insurance coverage. The strong relationship between insurance coverage and health services utilization highlights the importance of reaching out to the uninsured via prevention campaigns and communication messages. This article examines the communication choices of the uninsured, documenting that the uninsured are more likely to consume entertainment-based television and are less likely to read, watch, and listen to information-based media. It further documents the positive relationship between interpersonal communication, community participation, and health insurance coverage. The entertainment-heavy media consumption patterns of the uninsured suggests the relevance of developing health marketing strategies that consider entertainment programming as an avenue for reaching out to this underserved segment of the population.

Use of substance abuse services by young uninsured american adults

OBJECTIVES

This study examined the prevalence and correlates of substance abuse service use among uninsured young adults aged 18 to 34 years (N=24,282).

METHODS

Data were drawn from the 1999 National Household Survey on Drug Abuse. Logistic regression was used to identify correlates of substance abuse service use among persons who met DSM-IV criteria for dependence.

RESULTS

Among uninsured young adults (N=5,067), 66 percent lacked any health care coverage for at least one year. In this uninsured group, 72 percent were past-year users of alcohol or drugs (N=2,335). Among past-year alcohol users (N=2,273), 12 percent met criteria for alcohol dependence; among past-year drug users (N=864), 21 percent met dependence criteria. Eighty-seven percent of the uninsured young adults with alcohol or drug dependence did not receive any substance abuse treatment services in the previous year. In the uninsured substance-dependent group, women, blacks, and Hispanics were less likely than men and whites to use substance abuse services. Among those with substance dependence, uninsured persons were more likely than privately insured persons to receive substance abuse services from the self-help or human service (nonmedical) sector.

CONCLUSIONS

Racial, ethnic, and gender disparities in the use of substance abuse services are notable among young adults who lack health insurance.

Is it really worse to have public health insurance than to have no insurance at all? Health insurance and adult health in the United States

Using prospective cohort data from the 1979 National Longitudinal Survey of Youth, this study examines the extent to which health insurance coverage and the source of that coverage affect adult health. While previous research has shown that privately insured nonelderly individuals enjoy better health outcomes than their uninsured counterparts, the same relationship does not hold for those publicly insured through programs such as Medicaid. Because it is unclear whether this finding reflects a true causal relationship or is in fact due to selection bias on socioeconomic status and health, previous estimates of the contribution of health insurance to inequities in health may have been biased. This study attempts to disentangle these competing hypotheses of causation or selection bias by using fixed effects models with sibling clusters to corroborate--or contradict--the results of a conventional OLS regression. By controlling for unobserved factors shared by siblings, such as parental genetic influences, sibling models estimate health insurance effects that are less affected by selection bias. Findings suggest that, among the US. birth cohorts of 1957 to 1961, the negative relationship between public health insurance and health is not causal, but rather due to prior health and socioeconomic status. Conversely, the lack of health insurance coverage has a strong cumulative negative impact on adult health.

Substance use, dependence, and service utilization among the US uninsured nonelderly population

OBJECTIVES

We examined the prevalence and correlates of substance use, dependence, and service utilization among uninsured persons aged 12 to 64 years.

METHODS

We drew study data from the 1998 National Household Survey on Drug Abuse.

RESULTS

An estimated 80% of uninsured nonelderly persons reported being uninsured for more than 6 months in the prior year. Only 9% of these uninsured persons who were dependent on alcohol or drugs had received any substance abuse service in the past year. Non-Hispanic Whites were an estimated 3 times more likely than Blacks to receive substance abuse services.

CONCLUSIONS

Compared with the privately insured, uninsured persons had increased odds of having alcohol/drug dependence and appeared to face substantial barriers to health services for substance use problems.

Receipt of preventive services among privately insured minorities in managed care versus fee-for-service insurance plans

OBJECTIVE

We compare preventive services utilization among privately insured African Americans and Hispanics in managed care organizations (MCOs) versus fee-for-service (FFS) plans. We also examine racial/ethnic disparities in the receipt of preventive services among enrollees in FFS or MCO plans.

DESIGN

Analysis of the nationally representative 1996 Medical Expenditure Panel Survey.

PARTICIPANTS

Participants included 1,120 Hispanic, 929 African-American, and 6,383 non-Hispanic white (NHW) adults age 18 to 64 years with private health insurance.

MEASUREMENTS AND MAIN RESULTS

We examined self-reported receipt of physical examination, blood pressure measurement, cholesterol assessment, Papanicolau testing, screening mammography, and breast and prostate examinations. Multivariate modeling was used to adjust for age, gender, education, household income, and health status. Hispanics in MCOs were more likely than their FFS counterparts to report having preventive services, with adjusted differences ranging from 5 to 19 percentage points (P <.05 for physical examination, blood pressure measurement, breast examination and Pap smear). Among African Americans, such patterns were of a smaller magnitude. In both MCOs and FFS plans the proportion of African Americans reporting preventive services was equal to or greater than NHWs. In contrast, among Hispanic women in FFS, a non-statistically significant trend of fewer cancer screening tests than NHW's was observed (Pap smears 75% vs 80%; mammograms 66% vs 74%, respectively). In both MCO and FFS plans, Hispanics were less likely than NHWs to report having blood pressure and cholesterol measurement (P <.05).

CONCLUSIONS

With the demise of traditional MCOs, reform efforts should incorporate those aspects of MCOs that were associated with greater preventive service utilization, particularly among Hispanics. Existing ethnic disparities warrant further attention.

Self-reported health status of low-income mothers

PURPOSE

To determine the self-reported health status of low-income mothers before major health and welfare policy reform in the state of Ohio, to compare the health status of this group with the general population age-based norms, and to examine differences in health status among insurance and racial subgroups. Policy makers and others have a need for key health-status information about low-income mothers, a topic for which little empirical data currently exist.

DESIGN

Descriptive using a cross-sectional survey with convenience sampling; 502 women were interviewed at intake sites in four countries in central Ohio, 1995 to 1996.

METHODS

Health status was measured using the general health status index developed by J. E. Ware and colleagues (1995). Two summary measures, one indicating physical health and one indicating mental health, were used and compared with published norms. Multivariate logistic models were examined for depression and physical health status.

FINDINGS

A significant level of depression in the population of low-income mothers was found as were differences in physical health scores by insurance group. People insured privately had the highest physical health scores, while those enrolled in fee-for-service Medicaid had scores indicating the poorest health. No significant difference was found between racial groups in self-reported health status.

CONCLUSIONS

Self-reported mental health status is low among some low-income female populations. Physical health is worse for the Medicaid-enrolled group compared to both uninsured and privately insured groups. This poor state of health will likely diminish the success of welfare reform to improve the economic self-sufficiency of these women unless comprehensive health services are available.

Health care coverage and use of preventive services among the near elderly in the United States

OBJECTIVES

It has been proposed that individuals aged 55 to 64 years be allowed to buy into Medicare. This group is more likely than younger adults to have marginal health status, to be separating from the workforce, to face high premiums, and to risk financial hardship from major medical illness. The present study examined prevalence of health insurance coverage by demographic characteristics and examined how lack of insurance may affect use of preventive health services.

METHODS

Data were obtained from the Behavioral Risk Factor Surveillance System, an ongoing telephone survey of adults conducted by the 50 states and the District of Columbia.

RESULTS

Many near-elderly adults least likely to have health care coverage were Black or Hispanic, had less than a high school education and incomes less than $15,000 per year, and were unemployed or self-employed. Health insurance coverage was associated with increased use of clinical preventive services even when sex, race/ethnicity, marital status, and educational level were controlled.

CONCLUSIONS

Many near-elderly individuals without insurance will probably not be able to participate in a Medicare buy-in unless it is subsidized in some way.

Hypertension-related morbidity and mortality in the southeastern United States

Stroke mortality is higher in the Southeast compared with other regions of the United States. The prevalence of hypertension is also higher (black men = 35%, black women = 37.7%, white men = 26.5%, white women = 21.5%), and the proportion of patients whose hypertension is being controlled is poor, especially in white and black men. The prevalence of hypertension-related complications other than stroke is also higher in the Southeast. The five states with the highest death rates for congestive heart failure are all in the southern region. Of the 15 states with the highest rates of end-stage renal disease, 10 are in the Southeast. Obesity is very prevalent (24% to 28%) in the Southeast. Although Michigan tops the ranking for all states, 6 of the top 15 states are in the Southeast, as are 7 of the 10 states with the highest reported prevalence regarding no leisure-time physical activity. Similar to other areas of the United States, dietary sodium and saturated fat intake are high in the Southeast; dietary potassium intake appears to be relatively low. Other factors that may be associated with the high prevalence, poor control, and excess morbidity and mortality of hypertension-related complications in the Southeast include misperceptions of the seriousness of the problem, the severity of the hypertension, lack of adequate follow-up, reduced access to health care, the cost of treatment, and possibly, low birth weights. The Consortium of Southeastern Hypertension Control (COSEHC) is a nonprofit organization created in 1992 in response to a compelling need to improve the disproportionate hypertension-related morbidity and mortality throughout this region. The purpose of this position paper is to summarize the data that document the problem, the consequences, and possible causative factors.