Why is there state variation in employer-sponsored insurance?

Determining the Existence and Strength of Teen Dating Violence Policy: Testing a Comparative State Internal Determinants Model

Research demonstrates that Teen Dating Violence (TDV) programs impact TDV knowledge, attitudes, and behaviors, decreasing the odds of TDV victimization and perpetration. Studies indicate that students who do not complete a TDV intervention have significantly higher odds of physical and emotional TDV victimization and emotional TDV perpetration. This study uses multiple logistic regression and multiple linear regression to examine predictors of the presence and the strength of state legislation addressing TDV education and school policies. Results indicate some success in predicting the existence of TDV laws but less support for forecasting the strength of the policies passed. Dominant political party and state median income were found to be potentially important determinants of TDV state school policies. A state's political culture influenced the strength of states' TDV policies. Showing that policy existence and strength are related to different processes is important for advocates to understand. Future research should look at additional variables and explore legislative histories.

Medicare Enrollment Rates Across Six Asian Subgroups in the USA

OBJECTIVES

Although Medicare is a vital source of health insurance coverage for older Americans, little is known about Medicare enrollment among older Asians. This study aimed to examine heterogeneity in Medicare enrollment across the six largest subgroups of Asian Americans (Chinese, Japanese, Filipino, Indian, Korean, and Vietnamese), in relation to their citizenship status and labor force participation.

METHODS

Data from the American Community Survey Public Use Microdata Sample (2014-2018) were analyzed for older foreign-born Asians aged 65 or older (N = 83,378). A two-level multilevel logistic regression model (states > individuals) was used to model the probabilities of Medicare enrollment, accounting for state-level residential clustering by Asian subgroup and, thus, for nonindependence among respondents from the same state.

RESULTS

The results indicated a substantial amount of heterogeneity in Medicare enrollment across the six Asian subgroups. Although the overall Medicare enrollment rate was low (90.2%), the rates varied from 85.5% among Indians to 93.8% among Koreans and Japanese. Naturalized citizens and those not in the labor force were associated with greater probabilities of Medicare enrollment. However, the relative differences in the Medicare enrollment rates across the six Asian subgroups were different by individuals' naturalization status and labor force participation (i.e., significant three-way interactions).

DISCUSSION

These results highlight that aggregated data cannot accurately represent Medicare and health insurance status of older Asians with different sub-ethnic backgrounds. Intragroup and intergroup differences in Medicare enrollment among foreign-born older Asians should be considered for targeted policy approaches for this group of older adults.

Non-Medicare Enrollees Aged 65 or Older: The Effects of Labor-Force Participation, Citizenship, and Age

This study investigated the relationships among age, labor force participation, and citizenship status in relation to non-Medicare enrollment among individuals aged 65 years or older. Two-level multilevel modeling (states > individuals) with a nationally representative sample of 566,003 individuals was conducted to control for state-level variations in non-Medicare enrollment rates. Among those aged 65 to 66 years, 11.2% were non-Medicare enrollees nationwide. However, analyses indicated significant differences in non-Medicare enrollment rates by age, labor force participation, citizenship status, and state of residence. Moreover, the relationship between labor force participation and age was different between U.S. citizens and noncitizens (i.e., a significant three-way interaction). Specifically, labor force participation was associated with greater probabilities of non-Medicare enrollment among U.S. citizens aged between 65 and 69 years, although the opposite was true among noncitizens. While reasons for non-Medicare enrollment appear voluntary for some older adults (i.e., employment), some associated factors indicate subpopulations of vulnerable non-Medicare enrollees (i.e., noncitizens, aged 70+).

Effects of Public Premiums on Children's Health Insurance Coverage: Evidence from 1999 to 2003

This study uses 2000 to 2004 Current Population Survey data to examine the effects of public premiums on the insurance coverage of children whose family incomes are between 100% and 300% of the federal poverty level. The analysis employs multinomial logistic models that control for factors other than premium costs. While the magnitude of the estimated effects varies across models, the results consistently indicate that raising public premiums reduces enrollment in public programs, with some children who forgo public coverage having private coverage instead and others being uninsured. The results indicate that public premiums have larger effects when applied to lower-income families.

Sub-Ethnic and Geographic Variations in Out-of-Pocket Private Health Insurance Premiums Among Mid-Life Asians

OBJECTIVE

This study examined out-of-pocket premium burden of mid-life Asian Americans by comparing six sub-groups of Asians after controlling for geographic clustering at the county and state levels.

METHOD

The 2007-2011 National Health Interview Survey was linked to community-level data and analyzed for 4,628 Asians (ages 50-64), including 697 Asian Indians, 1,125 Chinese, 1,393 Filipinos, 434 Japanese, 524 Koreans, and 455 Vietnamese. Non-Hispanic Whites were included as a comparison group ( n = 48,135). Three-level multilevel modeling (state > county > individual) was conducted.

RESULTS

Koreans and Vietnamese were found as vulnerable sub-groups considering their lower private health insurance rates and higher uninsured rates. Among those with private insurance, Asians, specifically Filipinos, paid significantly less than non-Hispanic Whites. Moderate but significant variations in the county- and state-level variance in out-of-pocket premiums were found, especially among mid-life Asians.

DISCUSSION

This study demonstrates the importance of examining within-group heterogeneity and geographic variations in understanding premium burden among mid-life Asians.

Work ability and labor supply after kidney transplantation

BACKGROUND

The vocational rehabilitation after kidney transplantation (KTX) is suboptimal. We sought to evaluate correlates of occupational outcomes after KTX.

METHODS

We included 336 working-age patients with at least one creatinine assessment in the 3-month screening period. We collected clinical information from medical records. All subjects answered a self-administered questionnaire, and a follow-up questionnaire was mailed to each participant after 6 months. Study outcomes were the Work Ability Index (WAI) and labor supply (the number of days each patient worked in the follow-up period). We estimated the glomerular filtration rate (eGFR) with the Modification of Diet in Renal Disease Study equation.

RESULTS

The mean eGFR was 52.76 ± 23.68 ml/min/1.73 m(2). The age-standardized employment-to-population ratio was 62%. Comorbidities, self-reported work ability, gender, age, health insurance type, and time since transplant were associated with employment status at baseline. The WAI (38.79 ± 5.88) was associated with the severity of renal impairment, work attachment and comorbidities. After 6 months, labor supply (mean 19.4 ± 9.7 weeks) was associated with WAI item 1 (ρ = 0.22; p = 0.03); eGFR was significantly associated with labor supply, and this association was slightly stronger in patients with physically demanding jobs.

CONCLUSIONS

We identified modifiable factors associated with poor occupational outcomes in kidney transplant recipients. Consistent with labor supply theory, our results suggest that health care coverage plays a key role in employment decisions after KTX independent of possible confounders. Additionally, our study provides the rationale to further evaluate the implications of renal function-preserving strategies for indirect cost savings and self-reported ability to work after transplant.

Decomposition of the drivers of the U.S. hospital spending growth, 2001-2009

BACKGROUND

United States health care spending rose rapidly in the 2000s, after a period of temporary slowdown in the 1990s. However, the description of the overall trend and the understanding of the underlying drivers of this trend are very limited. This study investigates how well historical hospital cost/revenue drivers explain the recent hospital spending trend in the 2000s, and how important each of these drivers is.

METHODS

We used aggregated time series data to describe the trend in total hospital spending, price, and quantity between 2001 and 2009. We used the Oaxaca-Blinder method to investigate the relative importance of major hospital cost/spending drivers (derived from the literature) in explaining the change in hospital spending patterns between 2001 and 2007. We assembled data from Medicare Cost Reports, American Hospital Association annual surveys, Prospective Payment System (PPS) Impact Files, Medicare Provider Analysis and Review (MedPAR) Medicare claims data, InterStudy reports, National Health Expenditure data, and Area Resource Files.

RESULTS

Aggregated time series trends show that high hospital spending between 2001 and 2009 appears to be driven by higher payment per unit of hospital output, not by increased utilization. Results using the Oaxaca-Blinder regression decomposition method indicate that changes in historically important spending drivers explain a limited 30% of unit-payment growth, but a higher 60% of utilization growth. Hospital staffing and labor-related costs, casemix, and demographics are the most important drivers of higher hospital revenue, utilization, and unit-payment. Technology is associated with lower utilization, higher unit payment, and limited increases in total revenue. Market competition, primarily because of increased managed care concentration, moderates total revenue growth by driving lower unit payment.

CONCLUSIONS

Much of the rapidly rising hospital spending growth in the 2000s in the United States is driven by factors not commonly known or well measured. Future studies need to explore new factors and dynamics that drive longer-term hospital spending growth in recent years, particularly through the channel of higher prices.

Sociodemographic correlates of eye care provider visits in the 2006-2009 Behavioral Risk Factor Surveillance Survey

Background

Research has suggested that adults 40 years old and over are not following eye care visit recommendations. In the United States, the proportion of older adults is expected to increase drastically in the coming years. This has important implications for population ocular disease burden, given the relationship between older age and the development of many ocular diseases and conditions. Understanding individual level determinants of vision health could support the development of tailored vision health campaigns and interventions among our growing older population. Thus, we assessed correlates of eye care visits among participants of the Behavior Risk Factor Surveillance System (BRFSS) survey. We pooled and analyzed 2006–2009 BRFSS data from 16 States (N = 118,075). We assessed for the proportion of survey respondents 40 years of age and older reporting having visited an eye care provider within the past two years, two or more years ago, or never by socio-demographic characteristics.

Results

Nearly 80% of respondents reported an eye care visit within the previous two years. Using the ‘never visits’ as the referent category, the groups with greater odds of having an ocular visit within the past two years included those: greater than 70 years of age (OR = 6.8 [95% confidence interval = 3.7–12.6]), with college degree (5.2[3.0–8.8]), reporting an eye disease, (4.74[1.1–21.2]), diagnosed with diabetes (3.5[1.7–7.5]), of female gender (2.9[2.1–3.9]), with general health insurance (2.7[1.8–3.9]), with eye provider insurance coverage (2.1[1.5–3.0]), with high blood pressure (1.5[1.1–2.2]), and with moderate to extreme near vision difficulties (1.42[1.11–2.08]).

Conclusion

We found significant variation by socio-demographic characteristics and some variation in state-level estimates in this study. The present findings suggest that there remains compliance gaps of screening guidelines among select socio-demographic sub-groups, as well as provide evidence and support to the CDC’s Vision Health Initiative. This data further suggests that there remains a need for ocular educational campaigns in select socio-demographic subgroups and possibly policy changes to enhance insurance coverage.

Family obligations and support behaviour: a United States–Netherlands comparison

This study draws on national survey data from the United States of America (USA) and the Netherlands to compare family obligations and support behaviour for middle-generation adults who have a living aged parent and adult child. Consistent with a familialism by default hypothesis based on welfare state differences, the US sample espouses stronger family obligations than the Dutch sample. Yet, the Dutch respondents are more likely to engage in family support behaviours with both the younger and older generations, contrary to a family-steps-in hypothesis. The connection between family obligations and support behaviour is also tested, revealing a stronger association in the US sample, consistent with a family-steps-in hypothesis, but only in regard to relations with ageing parents. We conclude that Dutch respondents are more likely to act on their individual preferences whereas American respondents are more influenced by general norms of obligation towards family members. The findings are discussed in terms of social policy differences between the two countries, and in light of results from comparative European studies of intergenerational relations.

State and metropolitan variation in lack of health insurance among working-age adults, Behavioral Risk Factor Surveillance System, 2006

OBJECTIVE

Lack of health insurance coverage for working-age adults is one of the most pressing issues facing the U.S. population, and it continues to be a concern for a large number of people. In the absence of a national solution, the states and municipalities are left to address this need. We examined the disparities in uninsurance prevalence by state and metropolitan areas in the U.S. and among racial/ethnic groups.

METHOD

Data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed for working-age adults 18 to 64 years of age.

RESULTS

In 2006, according to the BRFSS data, overall 18.6% (standard error = 0.20) of working-age adults were without health insurance coverage; by state, this proportion ranged from 9.7% to 29.0%. Health insurance coverage varied by state and metropolitan area and racial/ethnic group, and a higher age-adjusted prevalence of uninsurance was observed for non-Hispanic black and Hispanic respondents.

CONCLUSIONS

A substantial proportion of working-age Americans remain without health insurance coverage. Disparities in health insurance coverage were observed by population and geographic groups. Overall, black and Hispanic populations fared far worse in terms of lack of health-care coverage than working-age white Americans.

State variation in health insurance coverage for U.S. citizen children of immigrants

In this paper we compare health insurance coverage for U.S. citizen children in all-citizen and mixed families in the fifteen states with the largest share of children in mixed families. Insurance coverage is lower and state variation in coverage is higher for children in mixed families vis-à-vis children in all-citizen families. The main challenges for states are tackling uninsurance among all low-income children and addressing the very low rates of employer-sponsored insurance for all low-income children and for children in all mixed families, regardless of income. We discuss state policy options to address the needs of children in mixed families.

Body mass index and employment-based health insurance

Background

Obese workers incur greater health care costs than normal weight workers. Possibly viewed by employers as an increased financial risk, they may be at a disadvantage in procuring employment that provides health insurance. This study aims to evaluate the association between body mass index [BMI, weight in kilograms divided by the square of height in meters] of employees and their likelihood of holding jobs that include employment-based health insurance [EBHI].

Methods

We used the 2004 Household Components of the nationally representative Medical Expenditure Panel Survey. We utilized logistic regression models with provision of EBHI as the dependent variable in this descriptive analysis. The key independent variable was BMI, with adjustments for the domains of demographics, social-economic status, workplace/job characteristics, and health behavior/status. BMI was classified as normal weight (18.5–24.9), overweight (25.0–29.9), or obese (≥ 30.0). There were 11,833 eligible respondents in the analysis.

Results

Among employed adults, obese workers [adjusted probability (AP) = 0.62, (0.60, 0.65)] (P = 0.005) were more likely to be employed in jobs with EBHI than their normal weight counterparts [AP = 0.57, (0.55, 0.60)]. Overweight workers were also more likely to hold jobs with EBHI than normal weight workers, but the difference did not reach statistical significance [AP = 0.61 (0.58, 0.63)] (P = 0.052). There were no interaction effects between BMI and gender or age.

Conclusion

In this nationally representative sample, we detected an association between workers' increasing BMI and their likelihood of being employed in positions that include EBHI. These findings suggest that obese workers are more likely to have EBHI than other workers.

International medical graduate physicians in the United States: changes since 1981

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)--physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.

What's driving the downward trend in employer-sponsored health insurance?

OBJECTIVE

We investigate the factors driving the downward trend in employer sponsored health insurance (ESI) coverage between 1999 and 2002 for low- and middle-income workers, and assess their insurance options in the absence of ESI coverage.

DATA

We use the 1999 and 2002 rounds of the National Survey of America's Families (NSAF), supplemented with ESI premiums from the Medical Expenditure Panel Survey, as well as other state- and county-level data from a variety of sources. The sample includes workers between the ages of 19 and 64.

STUDY DESIGN

We first estimate linear probability models of the probability of having an ESI offer and, for those with an offer, the probability of taking up ESI coverage, using two-stage least square regression on the 2002 worker sample. We then use Oaxaca-Blinder regression-based decomposition methods to identify the factors that explain the changes in ESI offer and take-up between 1999 and 2002.

PRINCIPAL FINDINGS

We find that while low-income workers are more likely to be uninsured and are most vulnerable to the loss of ESI coverage, many middle-income workers are also in a precarious position when faced with the loss of ESI coverage. Many low- and middle-income workers have few coverage options in the absence of ESI. This is particularly problematic for low-income workers: only 13 percent have a spouse with an ESI offer and the nongroup premium they face increased at a much higher rate than for middle-income workers. Finally, we find that the drop in ESI offers between 1999 and 2002 was driven largely by changes in nature of the workers' jobs, while the drop in ESI take-up was driven largely by rising ESI premiums.

CONCLUSIONS

Policies that shore up the ESI system are important for both low- and middle-income workers, as both are vulnerable to a loss of insurance coverage in the absence of ESI. Over time, the potential coverage options available to low- and middle-income workers in the absence of ESI have narrowed as nongroup premiums have increased. While public coverage has provided some protection from that increase for low-income workers, middle-income workers are much less likely to have access to public protection.

State Variation In Medicaid Spending: Hard To Justify

There is great variation among states in Medicaid spending per low-income person. This variation has many determinants, including state discretion and differences in prices and amounts of services used. Incentives in Medicaid to have low-income states spend more have generally not worked. The decentralized approach to Medicaid and the variations in spending created thereby have consequences in access and health outcomes that seem to belie a presumed national interest in equity. The current trend toward state-based solutions to health care coverage would likely exacerbate existing variations. A federal solution, though not likely, would be necessary to eliminate state variations.

Children welcome, adults need not apply: changes in public program enrollment across states and over time

This article describes changes in the extent of public health insurance coverage for low-income children and adults from 1979 through 2001. Although previous research has demonstrated that public coverage among children has increased substantially during the past 20 years, our work shows that almost all of the increase has occurred among children in families with incomes between 100% and 200% of the federal poverty level (FPL), with little change among children in families with incomes below 100% of FPL. In contrast to the increase in public coverage among children, there has been virtually no change in the generosity of public programs for low-income adults. The overall stability of public coverage for adults masks substantial changes at the state level: public coverage for adults increased substantially in Tennessee, Vermont, Arizona, and other states that implemented Section 1115 Medicaid waivers, while declining in New York, California, and many Rust Belt states.

Rural-Urban Differences in Employment-Related Health Insurance

CONTEXT

Rural residents are disproportionately represented among the uninsured in the United States.

PURPOSE

We compared nonelderly adult residents in 3 types of nonmetropolitan areas with metropolitan workers to evaluate which characteristics contribute to lack of employment-related insurance. RESEARCH DESIGN AND ANALYSIS: Data were obtained from the Medical Expenditure Panel Survey, pooled across 3 panels (1996--1998) to enhance the rural sample size. Econometric decomposition was used to quantify the contribution of employment structure to differences in the probability of being offered employment-related health insurance.

FINDINGS

The most rural workers are 10.4 percentage points less likely to be offered insurance compared with urban workers; the difference is smaller for residents of other rural areas. In rural counties not adjacent to urban areas, lower wages and smaller employers each account for about one-third of the total difference.

CONCLUSIONS

Health insurance disparities associated with rural residence are related to the structure of employment. Major factors include smaller employers, lower wages, greater prevalence of self-employment, and sociodemographic characteristics.

Covering Kids: Variation In Health Insurance Coverage Trends By State, 1996–2002

We estimated state-specific changes in health insurance coverage rates for children between 1996-1998 and 2001-2002. We found considerable variation in the changing distribution of health insurance coverage for children across states, with significant increases in public program coverage in twenty-nine states and significant decreases in uninsured children in twenty-seven. Children in families with incomes below 200 percent of the federal poverty level were the most likely to enroll in public programs. We provide an overview of state outreach and administrative simplification efforts and raise concerns about the persistent variation in children's health insurance coverage across states.

State trends in uninsurance among individuals aged 18 to 64 years: United States, 1992-2001

OBJECTIVES

We analyzed state-specific uninsurance trends among US adults aged 18 to 64 years.

METHODS

We used logistic regression models to examine Behavioral Risk Factor Surveillance System data for uninsurance from 1992 to 2001 in 47 states.

RESULTS

Overall, uninsurance rates increased in 35 states and remained unchanged in 12 states. Increases were observed among people aged 30 to 49 years (in 34 states) and 50 to 64 years (in 24 states), and increases were also observed among individuals at middle and low income levels (in 39 states and 19 states, respectively), individuals employed for wages (in 33 states), and the self-employed (in 18 states).

CONCLUSIONS

Among adults aged 18-64, rates of uninsurance increased in most states from 1992 through 2001. Decreased availability of employer-sponsored health insurance, rising health care costs, and state fiscal crises are likely to worsen the growing uninsurance problem.

The Kindness Of Strangers: Community Effects On The Rate Of Employer Coverage

The rate of employer-sponsored insurance (ESI) varies greatly across states. We analyze the factors that account for that variation. We find that the likelihood that a worker is covered by ESI depends on workers' own characteristics and also on those of other workers in the same metropolitan statistical area. Further, in almost all states the percentage of workers covered by ESI is close to the predicted level of coverage, which suggests that state policies that could affect insurance coverage have had little net effect on ESI rates. Hawaii is an exception: Its mandate on employers to offer coverage results in a rate of ESI that is much higher than expected.

Mandating insurance offers for low-wage workers: an evaluation of labor market effects

Employing a simultaneous model of part-time status, health insurance offers, and wages, we examine the impacts on employment and health insurance coverage of nondiscrimination rules in the tax code governing employer-sponsored health insurance. Using 1988 and 1993 Employee Benefits Supplements to the Current Population Surveys and variations in health insurance premiums and minimum wages, we find that health insurance coverage among low-wage primary earners is increased by at most 31 percent by the policy, at a cost of an estimated 0.8-5.4-percentage-point decrease in full-time employment for low-wage workers.