Insured but not protected: how many adults are underinsured?

Bridging healthcare access: strategies beyond the COVID-19 public health emergency

Issued in January 2020, the federal Public Health Emergency (PHE)'s termination was ultimately inevitable and has prompted reflection over how the pandemic elicited relatively progressive reforms to healthcare. Although we are concerned that the PHE's termination poses a significant threat to public health and equity, we believe that physicians, along with systemic changes, can provide critical support for patients as they navigate a shifting health policy landscape. In response to this evolving landscape, the article emphasizes the pivotal role of physicians and healthcare institutions in safeguarding patient access to care. It proposes strategies such as community-based workshops, patient navigators, and streamlined technology-driven redetermination processes to support vulnerable populations during this transition. Physicians are encouraged to engage in advocacy efforts, from voicing concerns at health meetings to collaborating with non-profit organizations and the media, to influence data-driven policy changes that prioritize patient safety and equitable access. Marginalized patients should not be slipping through the cracks.

Can Medicaid be a Solution to the Problem? Underinsurance in Medicaid Expansion Versus Non-Expansion States

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.

Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues

Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.

Gender differences in the mechanism of involuntary retirement affecting loneliness through vulnerability and coping resources

Involuntary retirement is associated with diminished mental health. However, little is known about the mechanism that connects involuntary retirees' coping resources to their loneliness. Gender patterns in the mechanism of involuntary retirement are also unclear. This study examines gender differences in the link between involuntary retirement and loneliness through secondary stressors (material and physical vulnerability) and coping resources (social support and self-efficacy). Two-step structural equation modelling was used to examine the effects of several mediators. For both men and women, involuntary retirement was associated with increased loneliness in terms of physical vulnerability and social efficacy. We found the female involuntary retirees are facing loneliness with multiple mediating factors. The layers of experiencing loneliness among female retirees are (a) directly from involuntary retirement; (b) indirectly from involuntary retirement and secondary stressors (material vulnerability and physical vulnerability); and (c) indirectly from involuntary retirement, secondary stressors (material vulnerability and physical vulnerability) and coping resources. The specific gender differences in the complex mechanism leading to later-year loneliness among the retirees may inform the interventions and policies that mitigate the disadvantages among involuntarily retired older adults in the United States of America.

Health services utilization, out-of-pocket expenditure, and underinsurance among insured non-elderly cancer survivors in the United States, 2011-2015

BACKGROUND

High out-of-pocket (OOP) expenditure and inadequate insurance coverage may adversely affect cancer survivors. We aimed to characterize the extent and correlates of healthcare utilization, OOP expenditures, and underinsurance among insured cancer survivors.

METHODS

We used 2011-2015 Medical Expenditure Panel Survey data to identify a nationally representative sample of insured non-elderly adult (age 18-64 years) cancer survivors. We used negative binomial, two-part (logistic and Generalized Linear Model with log link and gamma distribution), and logistic regression models to quantify healthcare utilization, OOP expenditures, and underinsurance, respectively, and identified sociodemographic correlates for each outcome.

RESULTS

We identified 2738 insured non-elderly cancer survivors. Adjusted average utilization of ambulatory, non-ambulatory, prescription medication, and dental services was 14.4, 0.51, 24.9, and 1.4 events per person per year, respectively. Higher ambulatory and dental services utilization were observed in older adults, females, non-Hispanic Whites, survivors with a college degree and high income, compared to their counterparts. Nearly all (97.7%) survivors had some OOP expenditures, with a mean adjusted OOP expenditure of $1552 per person per year. Adjusted mean OOP expenditures for ambulatory, non-ambulatory, prescription medication, dental, and other health services were $653, $161, $428, $194, and $83, respectively. Sociodemographic variations in service-specific OOP expenditures were generally consistent with respective utilization patterns. Overall, 8.8% of the survivors were underinsured.

CONCLUSION

Many insured non-elderly cancer survivors allocate a substantial portion of their OOP expenditure for healthcare-related services and experience financial vulnerability, resulting in nearly 8.8% of the survivors being underinsured. Utilization of healthcare services varies across sociodemographic groups.

Types of multidimensional vulnerability and well-being among the retired in the U.S

BACKGROUND

An extensive study investigated the risk factors for low well-being in post-retirement. Most previous studies have taken a unidimensional perspective, focusing on single factors such as financial status, physical health, and mental health.

OBJECTIVE

Drawing on the vulnerability framework, we first identify and describe the empirical subgroups of vulnerability among retirees in the United States across four major domains of later life: material, physical, social, and mental vulnerability. Then, we investigate the association between vulnerability profiles and well-being.

METHOD

The sample included 3,158 retirees aged 65+ who participated in the Health and Retirement Study (HRS). Latent class analysis was utilized to identify the heterogeneous subgroups of vulnerability, and then a series of OLS regression analyses was conducted to examine the relationship between patterns of vulnerability and well-being.

RESULTS

Five vulnerability patterns were identified: material vulnerable (12%), health & social vulnerable (14%), material, health & social vulnerable (6%), least vulnerable (34%), and social vulnerable (35%). The health & social vulnerable group had the strongest negative influence on well-being among all subgroups. As the largest subgroup, the social vulnerable group's negative influence on well-being stood out, with a stronger effect than that of material privation experienced by those in the material vulnerable group.

CONCLUSION

By empirically identifying subgroups of differential vulnerability patterns among retirees, this study showed that post-retirement vulnerability reflects complex interactions among multiple disadvantages. Findings of this study enhance understanding of the disparities in well-being within the retired population, pointing to the possibility of targeted policy and program development.

Providing Hand Surgery Care to Vulnerably Uninsured Patients

Economically vulnerable US patients are at risk for undertreatment of hand-related conditions as well as poorer outcomes. The cost of indigent care can be substantial to both the patients and their communities. Caring for these patients in a system that depends on inconsistent coverage requires a network of safety-net hospitals. To ensure that patients have access to care, the protection of safety-net hospitals should be prioritized when discussing federal and state funding allocation. On an individual scale, surgeons can also make changes in their practices to help find sustainable ways to care for indigent patients.

Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017

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.

Single-payer or a multipayer health system: a systematic literature review

OBJECTIVES

Healthcare systems worldwide are actively exploring new approaches for cost containment and efficient use of resources. Currently, in a number of countries, the critical decision to introduce a single-payer over a multipayer healthcare system poses significant challenges. Consequently, we have systematically explored the current scientific evidence about the impact of single-payer and multipayer health systems on the areas of equity, efficiency and quality of health care, fund collection negotiation, contracting and budgeting health expenditure and social solidarity.

STUDY DESIGN

This is a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

METHODS

A search for relevant articles published in English was performed in March 2015 through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online through PubMed and Ovid, Health Technology Assessment Database, Cochrane database and WHO publications. We also searched for further articles cited by eligible papers.

RESULTS

A total of 49 studies were included in the analysis; 34 studied clinical outcomes of patients enrolled in different health insurances, while 15 provided a qualitative assessment in this field.

CONCLUSION

The single-payer system performs better in terms of healthcare equity, risk pooling and negotiation, whereas multipayer systems yield additional options to patients and are harder to be exploited by the government. A multipayer system also involves a higher administrative cost. The findings pertaining to the impact on efficiency and quality are rather tentative because of methodological limitations of available studies.

Perceived barriers to healthcare and receipt of recommended medical care among elderly Medicare beneficiaries

PURPOSE

Many Medicare beneficiaries perceive barriers to receiving healthcare, although the consequences are unknown. Facilitators can aid in the receipt of healthcare services. The objective was to assess the relationship between perceived facilitators and barriers to healthcare and actual receipt of recommended medical care among elderly beneficiaries.

METHODS

A cohort study using data from the 2001-2008 entry panels of the Medicare Current Beneficiary Survey that included 24,607 community-dwelling beneficiaries 65 years of age and older. Surveys elicited perceptions of healthcare with respect to: care coordination and quality; access to medical care; getting or delaying healthcare because of financial reasons; transportation; and usual source of care. The outcome was receipt of recommended medical care, expressed as an aggregate of 38 indicators covering initial evaluation, diagnostic tests, therapeutic interventions, hospitalization follow-up, and routine preventive care. Multivariable survey logistic regression produced odds ratios (ORs) and 95% confidence intervals (CIs) for receipt of recommended medical care, adjusted for sociodemographics, insurance, comorbidities, and disability.

RESULTS

Beneficiaries who reported having trouble getting or reported delaying healthcare because of financial reasons (barrier) (adjusted OR=0.79, 95% CI: 0.73-0.86) and those who reported having no usual source of care (facilitator) (adjusted OR=0.55, 95% CI: 0.48-0.63) were less likely to receive recommended medical care.

CONCLUSIONS

Survey data that capture patient perceptions of facilitators and barriers to healthcare may be useful for identifying system factors that affect timely receipt of recommended medical care. This information can inform the design of policies and programs to improve the healthcare of older adults.

Physical and/or Cognitive Impairment, Out-of-Pocket Spending, and Medicaid Entry among Older Adults

While Medicare provides health insurance coverage for those over 65 years of age, many still are underinsured, experiencing substantial out-of-pocket costs for covered and non-covered services as a proportion of their income. Using the Health and Retirement Study (HRS), this study found that being underinsured is a significant predictor of entering into Medicaid coverage over a 16-year period. The rate of entering Medicaid was almost twice as high for those who were underinsured and with physical and/or cognitive impairment than those who were not, while supplemental health insurance reduced the rate of entering Medicaid by 30 %. Providing more comprehensive coverage through the traditional Medicare program, including a ceiling on out-of-pocket expenditures or targeted support for those with physical or cognitive impairment, could postpone becoming covered by Medicaid and yield savings in Medicaid.

Lonely hearts don't get checked: On the role of social support in screening for cardiovascular risk

OBJECTIVE

Regular cardiovascular risk screening can prevent cardiovascular disease through timely implementation of lifestyle changes or medication. However, few studies have investigated what factors promote regular screening for risk factors like hypertension and high blood cholesterol. The aim of this study was to investigate the relationship between social support and adherence to cardiovascular risk screening.

METHODS

We analyzed data from the Spanish National Health Survey-a cross-sectional representative survey conducted by the Spanish Ministry of Health in 2012 (N=21,007). Participants reported whether they had their blood pressure and cholesterol levels measured by a health professional in the previous 12 months. Social support (i.e., the perception that emotional and practical support was available when needed) was measured with a validated scale. Multiple logistic regressions were conducted adjusted for demographic and health-related factors.

RESULTS

Compared to individuals who reported a lack of social support, individuals who perceived sufficient social support were on average twice more likely to report participation in blood pressure screening, OR=2.06, 95% CI [1.60, 2.66] and cholesterol screening, OR=2.85, 95% CI [1.99, 4.09]. These effects were uniform across different demographics and were replicated in a previous wave of the survey. Factors associated with worse screening adherence were low social class, being single or widowed, smoking, alcohol consumption, and no history of cardiovascular risk.

DISCUSSION

Perceptions of social support are positively related to cardiovascular risk screening adherence. Future research should investigate what type of social support most effectively increases screening participation among high risk populations.

The effect of Medicaid adult vision coverage on the likelihood of appropriate correction of distance vision: Evidence from the National Health and Nutrition Examination Survey

BACKGROUND

Medicaid is the main public health insurance program for individuals with low income in the United States. Some state Medicaid programs cover preventive eye care services and vision correction, while others cover emergency eye care only. Similar to other optional benefits, states may add and drop adult vision benefits over time.

RESEARCH OBJECTIVE

This article examines whether providing adult vision benefits is associated with an increase in the percentage of low-income individuals with appropriately corrected distance vision as measured during an eye exam.

METHODOLOGY

We estimate the effect of Medicaid vision coverage on the likelihood of having appropriately corrected distance vision using examination data from the 2001-2008 National Health and Nutrition Examination Survey. We compare vision outcomes for Medicaid beneficiaries (n = 712) and other low income adults not enrolled in Medicaid (n = 4786) before and after changes to state vision coverage policies.

FINDINGS

Between 29 and 33 states provided Medicaid adult vision benefits during 2001-2008, depending on the year. Our findings imply that Medicaid adult vision coverage is associated with a significant increase in the percentage of Medicaid beneficiaries with appropriately corrected distance vision of up to 10 percentage points.

CONCLUSION

Providing vision coverage to adults on Medicaid significantly increases the likelihood of appropriate correction of distance vision. Further research on the impact of vision coverage on related functional outcomes and the effects of Medicaid coverage of other services may be appropriate.

Impact of medical and behavioural factors on influenza-like illness, healthcare-seeking, and antiviral treatment during the 2009 H1N1 pandemic: USA, 2009-2010

We analysed a cross-sectional telephone survey of U.S. adults to assess the impact of selected characteristics on healthcare-seeking behaviours and treatment practices of people with influenza-like illness (ILI) from September 2009 to March 2010. Of 216,431 respondents, 8.1% reported ILI. After adjusting for selected characteristics, respondents aged 18-64 years with the following factors were more likely to report ILI: a diagnosis of asthma [adjusted odds ratio (aOR) 1.88, 95% CI 1.67-2.13] or heart disease (aOR 1.41, 95% CI 1.17-1.70), being disabled (aOR 1.75, 95% CI 1.57-1.96), and reporting financial barriers to healthcare access (aOR 1.63, 95% CI 1.45-1.82). Similar associations were seen in respondents aged ≥ 65 years. Forty percent of respondents with ILI sought healthcare, and 14% who sought healthcare reported receiving influenza antiviral treatment. Treatment was not more frequent in patients with high-risk conditions, except those aged 18-64 years with heart disease (aOR 1.90, 95% CI 1.03-3.51). Of patients at high risk for influenza complications, self-reported ILI was greater but receipt of antiviral treatment was not, despite guidelines recommending their use in this population.

Prevalence and predictors of underinsurance among low-income adults

BACKGROUND

Millions of adults will gain Medicaid or private insurance in 2014 under the Affordable Care Act, and prior research shows that underinsurance is common among middle-income adults. Less is known about underinsurance among low-income adults, particularly those with public insurance.

OBJECTIVE

To compare rates of underinsurance among low-income adults with private versus public insurance, and to identify predictors of being underinsured.

DESIGN

Descriptive and multivariate analysis of data from the 2005-2008 Medical Expenditure Panel Survey.

PARTICIPANTS

Adults 19-64 years of age with family income less than 125 % of the Federal Poverty Level (FPL) and full-year continuous coverage in one of four mutually exclusive insurance categories (N = 5,739): private insurance, Medicaid, Medicare, and combined Medicaid/Medicare coverage.

MAIN MEASURES

Prevalence of underinsurance among low-income adults, defined as out-of-pocket expenditures greater than 5 % of household income, delays/failure to obtain necessary medical care due to cost, or delays/failure to obtain necessary prescription medications due to cost.

KEY RESULTS

Criteria for underinsurance were met by 34.5 % of low-income adults. Unadjusted rates of underinsurance were 37.7 % in private coverage, 26.0 % in Medicaid, 65.1 % in Medicare, and 45.1 % among Medicaid/Medicare dual enrollees. Among underinsured adults, household income averaged $6,181 and out-of-pocket spending averaged $1,115. Due to cost, 8.1 % and 12.8 % deferred or delayed obtaining medical care or prescription medications, respectively. Predictors of underinsurance included being White, unemployed, and in poor health. After multivariate adjustment, Medicaid recipients were significantly less likely to be underinsured than privately insured adults (OR 0.22, 95 % CI 0.17-0.28).

CONCLUSIONS

Greater than one-third of low-income adults nationally were underinsured. Medicaid recipients were less likely to be underinsured than privately insured adults, indicating potential benefits of expanded Medicaid under health care reform. Nonetheless, more than one-quarter of Medicaid recipients were underinsured, highlighting the importance of addressing cost-related barriers to care even among those with public coverage.

Perceived health status and health insurance status: protective factors against health-related debt?

Current health care debate has largely focused on the need for health insurance coverage rather than quality coverage. Yet the economic downturn has resulted in an increasing number of individuals who are uninsured or underinsured, and consequently face financial hardships. Multivariate analyses were used with 95 adults to examine relationships between health insurance, health status, and health debt. Controlling for demographics, and human and financial capital, findings suggest that health debt is not related to health insurance or health status. However, individuals with post-secondary education and non-homeowners appear to be more at risk for accumulating health debt.

What Explains Divorced Women's Poorer Health?: The Mediating Role of Health Insurance and Access to Health Care in a Rural Iowan Sample*

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.

Impacts of rising health care costs on families with employment-based private insurance: a national analysis with state fixed effects

BACKGROUND

Given the rapid growth of health care costs, some experts were concerned with erosion of employment-based private insurance (EBPI). This empirical analysis aims to quantify the concern.

METHODS

Using the National Health Account, we generated a cost index to represent state-level annual cost growth. We merged it with the 1996-2003 Medical Expenditure Panel Survey. The unit of analysis is the family. We conducted both bivariate and multivariate logistic analyses.

RESULTS

The bivariate analysis found a significant inverse association between the cost index and the proportion of families receiving an offer of EBPI. The multivariate analysis showed that the cost index was significantly negatively associated with the likelihood of receiving an EBPI offer for the entire sample and for families in the first, second, and third quartiles of income distribution. The cost index was also significantly negatively associated with the proportion of families with EBPI for the entire year for each family member (EBPI-EYEM). The multivariate analysis confirmed significance of the relationship for the entire sample, and for families in the second and third quartiles of income distribution. Among the families with EBPI-EYEM, there was a positive relationship between the cost index and this group's likelihood of having out-of-pocket expenditures exceeding 10 percent of family income. The multivariate analysis confirmed significance of the relationship for the entire group and for families in the second and third quartiles of income distribution.

CONCLUSIONS

Rising health costs reduce EBPI availability and enrollment, and the financial protection provided by it, especially for middle-class families.

Underinsurance in the United States: an interaction of costs to consumers, benefit design, and access to care

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.

Nearly half of families in high-deductible health plans whose members have chronic conditions face substantial financial burden

High-deductible health plans-typically with deductibles of at least $1,000 per individual and $2,000 per family-require greater enrollee cost sharing than traditional plans. But they also may provide more affordable premiums and may be the lowest-cost, or only, coverage option for many families with members who are chronically ill. We surveyed families with chronic conditions in high-deductible plans and families in traditional plans to compare health care-related financial burden-such as experiencing difficulty paying medical or basic bills or having to set up payment plans. Almost half (48 percent) of the families with chronic conditions in high-deductible plans reported health care-related financial burden, compared to 21 percent of families in traditional plans. Almost twice as many lower-income families in high-deductible plans spent more than 3 percent of income on health care expenses as lower-income families in traditional plans (53 percent versus 29 percent). As health reform efforts advance, policy makers must consider how to modify high-deductible plans to reduce the financial burden for families with chronic conditions.

Communicating consequences of risky behaviors: Life expectancy versus risk of disease

OBJECTIVE

we investigate (1) whether presenting consequences of health-related behaviors in terms of life expectancy, rather than risk of disease, improves recall and (2) if yes, through which underlying mechanisms; (3) whether these effects hold for both low- and high-numeracy people and (4) in two countries with different cultural environments and medical systems.

METHODS

experiment within a computerized survey on probabilistic samples in the United States (n=513) and Germany (n=534).

RESULTS

when consequences of health-related behaviors were presented in terms of changes in life expectancy, recall was better than when they were presented in terms of risks of a disease both after 10min, Cohen's h=.51, F(1,543)=34.12, p=.001, and after 3 weeks, h=.62, F(1,543)=48.98, p=.001. This was so for participants of both high and low numeracy, and in both countries. The improved recall seems to be due to better imaginability of changes in life expectancy.

CONCLUSIONS

consequences of health-related behaviors are easier to imagine and are recalled better when expressed as changes in life expectancy rather than as changes in risk of diseases.

PRACTICE IMPLICATIONS

when communicating with patients about medical risks, we recommend using concepts that they can readily relate to their own everyday experiences.

Moral hazard matters: measuring relative rates of underinsurance using threshold measures

OBJECTIVE

To illustrate the impact of moral hazard for estimating relative rates of underinsurance and to present an adjustment method to correct for this source of bias.

DATA SOURCES/STUDY SETTING

Secondary data from the 2005 Medical Expenditure Panel Survey (MEPS) are used in this study. We restrict attention to households that report having employer-sponsored insurance (ESI) for all members during the entire 2005 calendar year.

STUDY DESIGN

Individuals or households are often classified as underinsured if out-of-pocket spending on medical care relative to income exceeds some threshold. In this paper, we show that, without adjustment, this common threshold measure of underinsurance will underestimate the number with low levels of insurance coverage due to moral hazard. We propose an adjustment method and apply it to the specific case of estimating the difference in rates of underinsurance among small- versus large-firm workers with full-year ESI.

DATA COLLECTION/EXTRACTION

Data were abstracted from the MEPS website. All analyses were performed in Stata 9.2.

PRINCIPAL FINDINGS

Applying the adjustment, we find that the underinsurance rate of small-firm households increases by approximately 20 percent with the adjustment for moral hazard and the difference in underinsurance rates between large-firm and small-firm households widens substantially.

CONCLUSIONS

Adjusting for moral hazard makes a sizeable difference in the estimated prevalence of underinsurance using a threshold measure.

Underinsurance and pediatric immunization delivery in the United States

BACKGROUND

Underinsured children are covered by private health insurance that does not cover the cost of vaccines, are not entitled to receive publicly purchased vaccines at no cost through the Vaccines for Children (VFC) Program unless they receive doses at a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC), may be referred by their primary care providers to health department clinics (HDCs) for vaccinations, and may have lower vaccination coverage for new and more expensive vaccines.

OBJECTIVES

To describe the estimated percentage of children in the U.S. who are underinsured, receive vaccine doses at HDCs, and are not VFC-entitled; and to evaluate the association between being underinsured, receiving vaccine doses at an HDC, and timely vaccination coverage.

METHODS

Subjects were 16,621 19-35 month-old children sampled by the National Immunization Survey in 2007.

RESULTS

Of all 19-35 month-old children, an estimated 10.5% were underinsured; and an estimated 1.4% were underinsured, received doses at an HDC, and were not VFC-entitled. Compared to fully insured children, children who were underinsured and received doses at an HDC had significantly lower vaccination coverage for the varicella (81.5% vs. 87.7%, p < 0.05) and PCV7 (55.1% vs. 75.9%, p < 0.05) vaccines.

CONCLUSIONS

Children who were underinsured and received doses at HDCs were found to have lower estimated timely vaccination coverage for recently recommended vaccines and more expensive varicella and PCV7 vaccines. To adequately vaccinate these children at HDCs, states require stable funding to pay for vaccines as the number of new and more expensive vaccines grows.

Underinsurance and adolescent immunization delivery in the United States

OBJECTIVE

The goal was to explore the association of being underinsured and receiving doses at a health department clinic (HDC) with not receiving all recommended adolescent vaccine doses.

METHODS

A total of 5657 adolescents, 13 to 17 years of age, were sampled in the National Immunization Survey-Teen in 2006-2007.

RESULTS

A total of 63.9% of all adolescents were covered by private health insurance. Among privately insured adolescents, approximately 31.3% were underinsured. Compared with fully insured adolescents, underinsured adolescents were more likely to receive doses at an HDC for tetanus-diphtheria toxoids/tetanus toxoids-reduced diphtheria toxoids-acellular pertussis vaccine (25.1% vs 6.2%; P < .05), tetravalent meningococcal conjugate vaccine (11.5% vs 2.5%; P < .05), and quadrivalent human papillomavirus vaccine (16.2% vs 3.4%; P < .05). Also, compared with fully insured adolescents, underinsured adolescents who received doses at an HDC had lower estimated rates of vaccination coverage for tetanus-diphtheria toxoids/tetanus toxoids-reduced diphtheria toxoids-acellular pertussis vaccine (58.5% vs 70.9%; P < .05), tetravalent meningococcal conjugate vaccine (10.8% vs 25.8%; P < .05), and quadrivalent human papillomavirus vaccine (7.8% vs 14.3%; P < .05).

CONCLUSION

Underinsured adolescents who receive doses at an HDC have lower rates of vaccination coverage than do fully insured adolescents.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age

OBJECTIVES

We examined associations between material resources and late-life declines in health.

METHODS

We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441).

RESULTS

Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage.

CONCLUSIONS

Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Communicating treatment risk reduction to people with low numeracy skills: a cross-cultural comparison

OBJECTIVES

We sought to address denominator neglect (i.e. the focus on the number of treated and nontreated patients who died, without sufficiently considering the overall numbers of patients) in estimates of treatment risk reduction, and analyzed whether icon arrays aid comprehension.

METHODS

We performed a survey of probabilistic, national samples in the United States and Germany in July and August of 2008. Participants received scenarios involving equally effective treatments but differing in the overall number of treated and nontreated patients. In some conditions, the number who received a treatment equaled the number who did not; in others the number was smaller or larger. Some participants received icon arrays.

RESULTS

Participants-particularly those with low numeracy skills-showed denominator neglect in treatment risk reduction perceptions. Icon arrays were an effective method for eliminating denominator neglect. We found cross-cultural differences that are important in light of the countries' different medical systems.

CONCLUSIONS

Problems understanding numerical information often reside not in the mind but in the problem's representation. These findings suggest suitable ways to communicate quantitative medical data.

Massachusetts health reform: employer coverage from employees' perspective

The national health reform debate continues to draw on Massachusetts' 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This study provides an update on employers' responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers' dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms.

Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets

OBJECTIVE

To estimate national total knee arthroplasty (TKA) rates by economic factors, and the extent to which differences in insurance coverage, income, and assets contribute to racial and ethnic disparities in TKA use.

DATA SOURCE

US longitudinal Health and Retirement Study survey data for the elderly and near-elderly (biennial rounds 1994-2004) from the Institute of Social Research, University of Michigan.

STUDY DESIGN

The outcome is dichotomous, whether the respondent received first TKA in the previous 2 years. Longitudinal, random-effects logistic regression models are used to assess associations with lagged economic indicators.

SAMPLE

Sample was 55,469 person-year observations from 18,439 persons; 663, with first TKA.

RESULTS

Racial/ethnic disparities in TKA were more prominent among men than women. For example, relative to white women, odds ratios (ORs) were 0.94, 0.46, and 0.79, for white, black, and Hispanic men, respectively (P < 0.05 for black men). After adjusting for economic factors, racial/ethnic differences in TKA rates for women essentially disappeared, while the deficit for black men remained large. Among Medicare-enrolled elderly, those with supplemental insurance may be more likely to have first TKA compared with those without it, whether the supplemental coverage was private [OR: 1.27; 95% confidence interval (CI): 0.82-1.96] or Medicaid (OR: 1.18; 95% CI: 0.93-1.49). Among the near-elderly (age 47-64), compared with the privately insured, the uninsured were less likely (OR: 0.61; 95% CI: 0.40-0.92) and those with Medicaid more likely (OR: 1.53; 95% CI: 1.03-2.26) to have first TKA.

CONCLUSIONS

Limited insurance coverage and financial constraints explain some of the racial/ethnic disparities in TKA rates.

Financial burden of health care, 2001-2004

Analysis of data from the Medical Expenditure Panel Survey (MEPS) shows that rising out-of-pocket expenses and stagnant incomes increased health spending's financial burden for families in 2001-2004, especially for the privately insured. High financial burdens among those with nongroup coverage increased by more than one-third. Despite evidence of increased cost sharing in private insurance plans, our analysis does not show that privately insured people paid a higher share of their total health care bill in 2004 compared to 2001. Financial burdens have increased to the point at which private insurance is no longer able to provide financial protection for an increasing number of families.

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

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

How much 'skin in the game' do medicare beneficiaries have? The increasing financial burden of health care spending, 1997-2003

Rising health costs and an aging population present critical policy challenges. This paper examines the financial burden of out-of-pocket health spending among Medicare beneficiaries between 1997 and 2003. Over this period, median out-of-pocket spending as a share of income increased from 11.9 percent to 15.5 percent. In 2003, the 25 percent of beneficiaries with the largest burden spent at least 29.9 percent of their income on health care, while 39.9 percent spent more than a fifth of their income on health care. Results suggest that sustained increases in out-of-pocket spending could make health care less affordable for all but the highest-income beneficiaries.

The U.S. presidential election and health care workforce policy

The candidates for the 2008 presidential election have offered a range of proposals that could bring significant changes in health care. Although few are aimed directly at the nurse and physician workforce, nearly all of the proposals have the potential to affect the health care workforce. Furthermore, the success of the proposed initiatives is dependent on a robust nurse and physician workforce. The purpose of this article is to outline the current needs and challenges for the nurse and physician workforce and highlight how candidates' proposals intersect with the adequacy of the health care workforce. Three general themes are highlighted for their implications on the physician and nurse workforce supply, including (a) expansion of health care coverage, (b) workforce investment, and (c) cost control and quality improvement.

Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys

OBJECTIVES

To compare mix of patients, scope of practice, and duration of visit in primary care physicians in Australia, New Zealand, and the United States.

DESIGN

Comparison of three comparable cross sectional surveys performed in 2001-2. Physicians completed a questionnaire on patients' demographics, diagnoses, and duration of visit.

SETTING

Primary care practice.

PARTICIPANTS

79,790 office visits in Australia, 10,064 in New Zealand, and 25,838 in the US.

MAIN OUTCOME MEASURES

Diagnostic codes were mapped to the Johns Hopkins expanded diagnostic clusters. Scope of practice was defined as the number of expanded diagnostic clusters accounting for 75% of all managed problems related to morbidity. Exposure to primary care was calculated from duration of visits recorded by the physician, and reports on rates of visits to primary care for each country.

RESULTS

In each country, primary care physicians managed an average of 1.4 morbidity related problems per visit. In the US, 46 expanded diagnostic clusters accounted for 75% of problems managed compared with 52 in Australia, and 57 in New Zealand. Correlations in the frequencies of managed health problems between countries were high (0.87-0.97 for pairwise comparisons). Though primary care visits were longer in the US than in New Zealand and Australia, the per capita annual exposure to primary care physicians in the US (29.7 minutes) was about half of that in New Zealand (55.5 minutes) and about a third of that in Australia (83.4 minutes) because of higher rates of visits to primary care in these countries.

CONCLUSIONS

Despite differences in the supply and financing of primary care across countries, many aspects of the clinical practice of primary care physicians are remarkably similar in Australia, New Zealand, and the US.

Money and mandates: relative effects of key policy levers in expanding health insurance coverage to all Americans

This study examines the relative effects of three policy levers on health coverage and costs in plans aimed at covering all Americans. Specifically, using microsimulation analysis and hypothetical proposals, it assesses how the generosity of financial assistance, an employer mandate, and an individual mandate affect the level of uninsurance, distribution of coverage, and federal costs, holding delivery system and benefits constant. The results suggest that only an individual mandate would cover all the uninsured; neither an employer mandate nor generous subsidies alone would be sufficient. The distribution of coverage would be least disrupted by an employer mandate, while 7.3% of people could lose employer coverage with generous subsidies and a voluntary purchasing pool. Federal costs would be highest under a combined individual and employer mandate since there would be costs to minimize disruption. Although less generous subsidies coupled with an individual mandate could yield universal coverage at a low federal cost, doing so would require large, new payments by individuals. Other key trade-offs are discussed.

Small-area estimation of health insurance coverage for California legislative districts

OBJECTIVES

To aid state and local policymakers, program planners, and community advocates, we created estimates of the percentage of the population lacking health insurance in small geographic areas of California.

METHODS

Finally, calibration ensured the consistency and stability of the estimates when they were aggregated.

RESULTS

Health insurance coverage among nonelderly persons varied widely across assembly districts, from 10% to 44%. The utility of local-level estimates was most apparent when the variations in subcounty uninsured rates in Los Angeles County (19%-44%) were examined.

CONCLUSIONS

Stable and useful estimates of health insurance rates for small areas such as legislative districts can be created through use of multiple sources of publicly available data.

Uninsured in America: problems and possible solutions

Failure to ensure access to health care for all lies at the heart of the US failure to achieve value for money, says Karen Davis

How much health insurance is enough? Revisiting the concept of underinsurance

There is little consensus on what constitutes adequate health insurance coverage. The concept of a lack of adequate coverage, or underinsurance, is a matter of ongoing debate. A measure of adequate coverage is of critical importance as the nature of health insurance products evolves. Changes to health coverage include more direct out-of-pocket spending by consumers and a reduction of covered benefits. This article updates and extends an earlier review of underinsurance measurement published in 1993. We present a conceptual approach to measuring underinsurance and provide a review of the empirical findings obtained from the application of these approaches. A discussion of the limitations in the selection of a measurement approach includes a review of the extant data sources used. We recommend a national effort to develop a consistent approach to monitor changes in the economic and structural dimensions of health insurance coverage with a concerted effort to define and measure underinsurance.

Out-Of-Pocket Health Spending And The Rural Underinsured

Multiple studies have documented higher uninsurance rates among rural compared to urban residents, yet the relative adequacy of coverage among rural residents with private health insurance remains unclear. This study estimates underinsurance rates among privately insured rural residents (both adjacent and nonadjacent to urban areas) and the characteristics associated with rural underinsurance. We found that 6 percent of privately insured urban residents were underinsured; the rate increased to 10 percent for rural adjacent and 12 percent for rural nonadjacent residents. Multivariate analyses suggest that rural residents' underinsurance status is related to the design of the private plans through which they have coverage.