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

Main Determinants of Supplementary Health Insurance Demand: (Case of Iran)

Introduction:

In the majority of developing countries, the volume of medical insurance services, provided by social insurance organizations is inadequate. Thus, supplementary medical insurance is proposed as a means to address inadequacy of medical insurance. Accordingly, in this article, we attempted to provide the context for expansion of this important branch of insurance through identification of essential factors affecting demand for supplementary medical insurance.

Method:

In this study, two methods were used to identify essential factors affecting choice of supplementary medical insurance including Classification and Regression Trees (CART) and Bayesian logit. To this end, Excel® software was used to refine data and R® software for estimation. The present study was conducted during 2012, covering all provinces in Iran. Sample size included 18,541 urban households, selected by Statistical Center of Iran using 3-stage cluster sampling approach. In this study, all data required were collected from the Statistical Center of Iran.

Results:

In 2012, an overall 8.04% of the Iranian population benefited from supplementary medical insurance. Demand for supplementary insurance is a concave function of age of the household head, and peaks in middle-age when savings and income are highest. The present study results showed greater likelihood of demand for supplementary medical insurance in households with better economic status, higher educated heads, female heads, and smaller households with greater expected medical expenses, and household income is the most important factor affecting demand for supplementary medical insurance.

Conclusion:

Since demand for supplementary medical insurance is hugely influenced by households’ economic status, policy-makers in the health sector should devise measures to improve households’ economic or financial access to supplementary insurance services, by identifying households in the lower economic deciles, and increasing their financial ability to pay. Moreover, insurance companies should adjust their insurance policy according to clients’ needs, household characteristics, and their incomes.

Lack of access due to costs remains a problem for some in Massachusetts despite the state's health reforms

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer. The state needs to implement new strategies to build on the promise of universal coverage and address specific needs of vulnerable populations, such as limiting out-of-pocket spending for this group. Also, more data are needed on the social determinants of health to identify specific barriers related to cost and access for vulnerable groups that general insurance reforms may not address.

Associations between minimum wage policy and access to health care: evidence from the Behavioral Risk Factor Surveillance System, 1996-2007

OBJECTIVES

We examined whether minimum wage policy is associated with access to medical care among low-skilled workers in the United States.

METHODS

We used multilevel logistic regression to analyze a data set consisting of individual-level indicators of uninsurance and unmet medical need from the Behavioral Risk Factor Surveillance System and state-level ecological controls from the US Census, Bureau of Labor Statistics, and several other sources in all 50 states and the District of Columbia between 1996 and 2007.

RESULTS

Higher state-level minimum wage rates were associated with significantly reduced odds of reporting unmet medical need after control for the ecological covariates, substate region fixed effects, and individual demographic and health characteristics (odds ratio = 0.853; 95% confidence interval = 0.750, 0.971). Minimum wage rates were not significantly associated with being uninsured.

CONCLUSIONS

Higher minimum wages may be associated with a reduced likelihood of experiencing unmet medical need among low-skilled workers, and do not appear to be associated with uninsurance. These findings appear to refute the suggestion that minimum wage laws have detrimental effects on access to health care, as opponents of the policies have suggested.

State variation in underinsurance among children with special health care needs in the United States

OBJECTIVE

National attention has focused on providing health insurance coverage for children. Less awareness has been given to underinsurance, particularly for children with special health care needs (CSHCN). Defined as having inadequate benefits, underinsurance may be a particular problem for CSHCN because of their greater needs for medical care.

METHODS

We used the 2005-2006 National Survey of Children With Special Health Care Needs, a nationally representative study of >40,000 CSHCN, to address state variations in underinsurance. CSHCN with health insurance were considered underinsured when a parent reported that the child's insurance did not usually or always cover needed services and providers or reasonably cover costs. We calculated the unadjusted prevalence of underinsurance for each state. Using logistic regression, we estimated state-specific odds and prevalence for underinsurance after adjusting for poverty level, race/ethnicity, gender, family structure, language use, insurance type, and severity of child's health condition. We also conducted multilevel analyses incorporating state-level contextual data on Medicaid and the State Children's Health Insurance Program.

RESULTS

Bivariate and multivariate analyses indicated that CSHCN's state of residence had a strong association with insurance adequacy. State-level unadjusted underinsurance rates ranged from 24% (Hawaii) to 38% (Illinois). After multivariate adjustments, the range was largely unchanged: 23% (Hawaii) to 38% (New Jersey). Multilevel analyses indicated that Medicaid income eligibility levels were inversely associated with the odds of being underinsured.

CONCLUSIONS

The individual-level and macro-level factors examined only partly explain state variations in underinsurance. Furthermore, the macro-level factors explained only a small portion of the variance; however, other macro-level factors may be relevant for the observed patterns.

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.

Mortality probability model III and simplified acute physiology score II: assessing their value in predicting length of stay and comparison to APACHE IV

BACKGROUND

To develop and compare ICU length-of-stay (LOS) risk-adjustment models using three commonly used mortality or LOS prediction models.

METHODS

Between 2001 and 2004, we performed a retrospective, observational study of 11,295 ICU patients from 35 hospitals in the California Intensive Care Outcomes Project. We compared the accuracy of the following three LOS models: a recalibrated acute physiology and chronic health evaluation (APACHE) IV-LOS model; and models developed using risk factors in the mortality probability model III at zero hours (MPM(0)) and the simplified acute physiology score (SAPS) II mortality prediction model. We evaluated models by calculating the following: (1) grouped coefficients of determination; (2) differences between observed and predicted LOS across subgroups; and (3) intraclass correlations of observed/expected LOS ratios between models.

RESULTS

The grouped coefficients of determination were APACHE IV with coefficients recalibrated to the LOS values of the study cohort (APACHE IVrecal) [R(2) = 0.422], mortality probability model III at zero hours (MPM(0) III) [R(2) = 0.279], and simplified acute physiology score (SAPS II) [R(2) = 0.008]. For each decile of predicted ICU LOS, the mean predicted LOS vs the observed LOS was significantly different (p <or= 0.05) for three, two, and six deciles using APACHE IVrecal, MPM(0) III, and SAPS II, respectively. Plots of the predicted vs the observed LOS ratios of the hospitals revealed a threefold variation in LOS among hospitals with high model correlations.

CONCLUSIONS

APACHE IV and MPM(0) III were more accurate than SAPS II for the prediction of ICU LOS. APACHE IV is the most accurate and best calibrated model. Although it is less accurate, MPM(0) III may be a reasonable option if the data collection burden or the treatment effect bias is a consideration.

Increased racial differences on breast cancer care and survival in America: historical evidence consistent with a health insurance hypothesis, 1975-2001

PURPOSE

This study examined whether race/ethnicity had differential effects on breast cancer care and survival across age strata and cohorts within stages of disease.

METHODS

The Detroit Cancer Registry provided 25,997 breast cancer cases. African American and non-Hispanic white, older Medicare-eligible and younger non-eligible women were compared. Successive historical cohorts (1975-1980 and 1990-1995) were, respectively, followed until 1986 and 2001.

RESULTS

African American disadvantages on survival and treatments increased significantly, particularly among younger women who were much more likely to be uninsured. Within node positive disease all treatment disadvantages among younger African American women disappeared with socioeconomic adjustment.

CONCLUSIONS

Growth of this racial divide implicates social, rather than biological, forces. Its elimination will require high quality health care for all.

Temporal trends in breast cancer mortality by state and race

OBJECTIVE

To examine how temporal trends in age-standardized female breast cancer death rates vary by state and race.

METHODS

We analyzed mortality data from the National Center for Health Statistics (NCHS) for the years 1975 through 2004 by state and race using joinpoint analyses.

RESULTS

By 2004, breast cancer death rates in white women were decreasing in all 50 states and the District of Columbia (DC), with the onset of decline varying by state. In contrast, among African American women, breast cancer death rates increased in two states (Arkansas and Mississippi) of the 37 states analyzed, were level in 24 states, and decreased in 11 states. In general, states that showed little progress in reducing breast cancer mortality rates over time had higher death rates in 2003-2004.

CONCLUSION

Trends in breast cancer death rates vary widely by state and are considerably less favorable in African American than in white women. State cancer control efforts should ensure that all women have access to high-quality early detection and treatment services.

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.

The inverse care law: implications for healthcare of vulnerable populations

Past and present, those with the greatest healthcare needs often receive the least adequate healthcare. This phenomenon, termed the "inverse care law," has implications for healthcare and outcomes for vulnerable populations including low-income persons, racial and ethnic minorities, and the uninsured among others. This article reviews disparities in health status and access to healthcare for vulnerable populations. It illustrates how concentration of risk factors within individuals, families, and communities worsens the paradox between healthcare need and access and highlights the models of healthcare delivery needed to adequately meet the needs of vulnerable populations.