Past Disruptions in Health Insurance Coverage and Access to Care Among Insured Adults

INTRODUCTION

Although the association between health insurance coverage and access to care is well documented, it is unclear whether the deleterious effects of being uninsured are strictly contemporaneous or whether previous disruptions in coverage have persistent effects. This study addresses this issue using nationally representative data covering 2011-2019 to estimate the extent to which disruptions in health insurance coverage continued to be associated with poor access even after coverage was regained.

METHODS

Analysis was conducted in 2022. Using a nationally representative cohort of insured adults aged 18-64 years (N=39,904) and multivariable logistic regression models, the authors estimated the association between past disruptions in coverage (occurring at least 1 year before) and the risks of lacking a usual source of care provider and having unmet medical need.

RESULTS

Among insured nonelderly adults, the risk of being without a usual source of care provider was between 18% (risk ratio=1.18; 95% CI=1.00, 1.38) and 75% higher (risk ratio=1.75; 95% CI=1.56, 1.93) than for those with continuous coverage; the risk of having unmet medical needs was between 41% (risk ratio=1.41; 95% CI=1.00, 1.83) and 66% (risk ratio=1.66; 95% CI=1.26, 2.06) higher. Longer insurance disruptions were associated with a higher risk of lacking a usual source of care provider.

CONCLUSIONS

Previous disruptions in health insurance coverage continued to be negatively associated with access to care for more than a year after coverage was regained. Improving access to care in the U.S. may require investing in policies and programs that help to strengthen coverage continuity among individuals with insurance coverage rather than focusing exclusively on helping uninsured individuals to gain coverage.

Perceptions of Patient-Provider Communication Across the Six Largest Asian Subgroups in the USA

BACKGROUND

Asians are the fastest-growing racial/ethnic minority group in the USA and many face communication barriers when seeking health care. Given that a high proportion of Asians are immigrants and have limited English proficiency, poor patient-provider communication may explain Asians' relatively low ratings of care. Though Asians are linguistically, economically, and culturally heterogeneous, research on health care disparities typically combines Asians into a single racial/ethnic category.

OBJECTIVES

To estimate racial/ethnic differences in perceptions of provider communication among the six largest Asian subgroups.

DESIGN AND PARTICIPANTS

Using a nationally representative sample of adults from the 2014-2017 Medical Expenditure Panel Survey (N = 136,836, round-specific response rates range from 72% to 98%), we estimate racial/ethnic differences in perceptions of provider communication, adjusted for English proficiency, immigration status, and sociodemographic characteristics.

MAIN MEASURES

The main dependent variable is a 4-item scale ranging from 0 to 100 measuring how positively patients view their health care providers' communication, adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS©) program. Respondents report how often their providers explain things clearly, show respect, listen carefully, and spend enough time with them.

KEY RESULTS

Asians, overall, had less positive perceptions of their providers' communication than either Whites or Latinxs. However, only Chinese-White differences remained after differences in English proficiency and immigration status were controlled (difference = - 2.67, 95% CI - 4.83, - 0.51). No other Asian subgroup differed significantly from Whites.

CONCLUSIONS

Negative views of provider communication are not pervasive among all Asians but, rather, primarily reflect the perceptions of Chinese and, possibly, Vietnamese patients. Researchers, policymakers, health plan executives, and others who produce or use data on patients' experiences with health care should, if possible, avoid categorizing all Asians into a single group.

Patient-Provider Communication Disparities by Limited English Proficiency (LEP): Trends from the US Medical Expenditure Panel Survey, 2006-2015

BACKGROUND

Individuals with limited English proficiency (LEP) have worse healthcare access and report lower quality of care compared to individuals who are proficient in English. Policy efforts to improve patient-provider communication for LEP individuals have been going on for decades but linguistic disparities persist.

OBJECTIVE

To describe trends in patient-provider communication by limited English proficiency (LEP) from 2006 to 2015.

DESIGN

We estimated interrupted time series models for three measures of patient-provider communication, testing for differences in both means (intercepts) and trends (slopes) before and after 2010 and differences in differences by English proficiency.

PARTICIPANTS

A nationally representative sample of the US non-institutionalized population with at least one office-based medical visit from the 2006-2015 Medical Expenditure Panel Survey (N = 27,001).

MAIN MEASURES

Patient-provider communication is measured with three variables indicating whether individuals reported that their providers always explained things in a way that was easy to understand, showed respect for what they had to say, and listened carefully.

KEY RESULTS

Although patient-provider communication improved for all groups over the study period, before 2010, it was getting worse among LEP individuals and disparities in patient-provider communication were widening. After 2010, patient-provider communication improved for LEP individuals and language disparities by English proficiency either narrowed or remained the same. For example, between 2006 and 2010, the percent of LEP individuals reporting that their provider explained things clearly declined by, on average, 1.4 percentage points per year (p value = 0.102); after 2010, it increased by 3.0 percentage points per year (p value = 0.003).

CONCLUSIONS

Our study sheds light on trends in patient-provider communication before and after 2010, a year that marked substantial efforts to reform the US healthcare system. Though patient-provider communication among LEP individuals has improved since 2010, linguistic disparities persist and constitute a formidable challenge to achieving healthcare equity, a long-standing US policy goal.

Do People with Health Insurance Coverage Who Live in Areas with High Uninsurance Rates Pay More for Emergency Department Visits?

OBJECTIVE

To investigate the relationship between the percent uninsured in a county and expenditures associated with the typical emergency department visit.

DATA SOURCES

The Medical Expenditure Panel Survey linked to county-level data from the American Community Survey, the Healthcare Cost and Utilization Project, and the Area Health Resources Files.

STUDY DESIGN

We use a nationally representative sample of emergency department visits that took place between 2009 and 2013 to estimate the association between the percent uninsured in counties and the amount paid for a typical visit. Final estimates come from a diagnosis-level fixed-effects model, with additional controls for a wide variety of visit, individual, and county characteristics.

PRINCIPAL FINDINGS

Among those with private insurance, we find that an increase of 1 percentage point in the county uninsurance rate is associated with a $20 increase in the mean emergency department payment. No such association is observed among visits covered by other insurance types.

CONCLUSIONS

Results provide tentative evidence that the costs associated with high uninsurance rates spill over to those with insurance, but future research needs to replicate these findings with longitudinal data and methods before drawing causal conclusions. Recent data on changes in area uninsurance rates following the ACA's insurance expansions and subsequent changes in emergency department expenditures afford a valuable opportunity to do this.

The availability of community health center services and access to medical care

BACKGROUND

Community Health Centers (CHCs) funded by Section 330 of the Public Health Service Act are an essential part of the health care safety net in the US. The Patient Protection and Affordable Care Act expanded the program significantly, but the extent to which the availability of CHCs improve access to care in general is not clear. In this paper, we examine the associations between the availability of CHC services in communities and two key measures of ambulatory care access - having a usual source of care and having any office-based medical visits over a one year period.

METHODS

We pooled six years of data from the Medical Expenditure Panel Survey (2008-2013) and linked it to geographic data on CHCs from Health Resources and Services Administration's Health Center Program Uniform Data System. We also link other community characteristics from the Area Health Resource File and the Dartmouth Institute's data files. The associations between CHC availability and our access measures are estimated with logistic regression models stratified by insurance status.

RESULTS

The availability of CHC services was positively associated with both measures of access among those with no insurance coverage. Additionally, it was positively associated with having a usual source of care among those with Medicaid and private insurance. These findings persist after controlling for key individual- and community-level characteristics.

CONCLUSIONS

Our findings suggest that an enhanced CHC program could be an important resource for supporting the efficacy of expanded Medicaid coverage under the Affordable Care Act and, ultimately, improving access to quality primary care for underserved Americans.

'Double jeopardy' measure suggests blacks and hispanics face more severe disparities than previously indicated

Eliminating disparities in health and health care is a long-standing objective of the US government. Racial and ethnic differences in insurance coverage pose a major obstacle to achieving this objective. With important coverage provisions of the Affordable Care Act beginning to take effect, we propose a new way of conceptualizing and quantifying the racial and ethnic disadvantages of uninsurance over the course of a lifetime. Using a life expectancy approach, we estimate the number of years whites, blacks, and Hispanics can expect to live in insurance "double jeopardy": being uninsured while also in lesser health and, therefore, at higher risk of needing medical care. Our measures indicate that compared to whites, Hispanics and blacks are more likely not only to be uninsured at any point throughout most of their lives, but also to spend more years uninsured and spend more of these uninsured years at high risk of needing medical care. These life expectancy measures--designed for ease of use by policy makers, researchers, and the general public--have the potential to reframe the discussion of disparities and monitor progress toward their elimination.

Race, place, and obesity: the complex relationships among community racial/ethnic composition, individual race/ethnicity, and obesity in the United States

OBJECTIVES

We explored the association between community racial/ethnic composition and obesity risk.

METHODS

In this cross-sectional study, we used nationally representative data from the Medical Expenditure Panel Survey linked to geographic data from the US Decennial Census and Census Business Pattern data.

RESULTS

Living in communities with a high Hispanic concentration (≥ 25%) was associated with a 0.55 and 0.42 increase in body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) and 21% and 23% higher odds for obesity for Hispanics and non-Hispanic Whites, respectively. Living in a community with a high non-Hispanic Asian concentration (≥ 25%) was associated with a 0.68 decrease in BMI and 28% lower odds for obesity for non-Hispanic Whites. We controlled for individual- and community-level social, economic, and demographic variables.

CONCLUSIONS

Community racial/ethnic composition is an important correlate of obesity risk, but the relationship differs greatly by individual race/ethnicity. To better understand the obesity epidemic and related racial/ethnic disparities, more must be learned about community-level risk factors, especially how built environment and social norms operate within communities and across racial/ethnic groups.

Unhealthy and uninsured: exploring racial differences in health and health insurance coverage using a life table approach

Millions of people in the United States do not have health insurance, and wide racial and ethnic disparities exist in coverage. Current research provides a limited description of this problem, focusing on the number or proportion of individuals without insurance at a single time point or for a short period. Moreover, the literature provides no sense of the joint risk of being uninsured and in need of medical care. In this article, we use a life table approach to calculate health- and insurance-specific life expectancies for whites and blacks, thereby providing estimates of the duration of exposure to different insurance and health states over a typical lifetime. We find that, on average, Americans can expect to spend well over a decade without health insurance during a typical lifetime and that 40% of these years are spent in less-healthy categories. Findings also reveal a significant racial gap: despite their shorter overall life expectancy, blacks have a longer uninsured life expectancy than whites, and this racial gap consists entirely of less-healthy years. Racial disparities in insurance coverage are thus likely more severe than indicated by previous research.

Community and individual race/ethnicity and home health care use among elderly persons in the United States

OBJECTIVE

To investigate whether the interaction between individual race/ethnicity and community racial/ethnic composition is associated with health-related home care use among elderly persons in the United States.

DATA SOURCES

A nationally representative sample of community-dwelling elders aged 65+ from the 2000 to 2006 Medical Expenditure Panel Survey (N=23,792) linked to block group-level racial/ethnic information from the 2000 Decennial Census.

DESIGN

We estimated the likelihood of informal and formal home health care use for four racial/ethnic elderly groups (non-Hispanic [NH] whites, NH-blacks, NH-Asians, and Hispanics) living in communities with different racial/ethnic compositions.

PRINCIPAL FINDINGS

NH-Asian and Hispanic elders living in block groups with ≥25 percent of residents being NH-Asian or Hispanic, respectively, were more likely to use informal home health care than their counterparts in other block groups. No such effect was apparent for formal home health care.

CONCLUSIONS

NH-Asian and Hispanic elders are more likely to use informal home care if they live in communities with a higher proportion of residents who share their race/ethnicity. A better understanding of how informal care is provided in different communities may inform policy makers concerned with promoting informal home care, supporting informal caregivers, or providing formal home care as a substitute or supplement to informal care.

Explaining Racial and Ethnic Differences in Antidepressant Use Among Adolescents

We investigate the extent to which antidepressant use among adolescents varies across racial and ethnic subgroups. Using a representative sample of U.S. adolescents, we find that non-Hispanic White adolescents are over twice as likely as Hispanic adolescents, and over five times as likely as non-Hispanic Black adolescents to use antidepressants. Results from a decomposition analysis indicate that racial/ethnic differences in characteristics, including household income, parental education, health insurance, and having a usual source of care explain between one half and two thirds of the gap in antidepressant use between Hispanics and non-Hispanic Whites. In contrast, none of the gap between Whites and Blacks in antidepressant use is explained by differences in observed characteristics. Further analysis suggests that there are large racial/ethnic differences in the extent to which behavioral and mental health problems prompt antidepressant use and that this may, in part, account for the large differences across race/ethnicity observed in our study.

Using Instrumental Variable (IV) Tests to Evaluate Model Specification in Latent Variable Structural Equation Models

Structural Equation Modeling with latent variables (SEM) is a powerful tool for social and behavioral scientists, combining many of the strengths of psychometrics and econometrics into a single framework. The most common estimator for SEM is the full-information maximum likelihood estimator (ML), but there is continuing interest in limited information estimators because of their distributional robustness and their greater resistance to structural specification errors. However, the literature discussing model fit for limited information estimators for latent variable models is sparse compared to that for full information estimators. We address this shortcoming by providing several specification tests based on the 2SLS estimator for latent variable structural equation models developed by Bollen (1996). We explain how these tests can be used to not only identify a misspecified model, but to help diagnose the source of misspecification within a model. We present and discuss results from a Monte Carlo experiment designed to evaluate the finite sample properties of these tests. Our findings suggest that the 2SLS tests successfully identify most misspecified models, even those with modest misspecification, and that they provide researchers with information that can help diagnose the source of misspecification.

The relationship between living arrangement and preventive care use among community-dwelling elderly persons

OBJECTIVES

We sought to examine the relationship between living arrangements and obtaining preventive care among the elderly population.

METHODS

We obtained data on 13,038 community-dwelling elderly persons from the 2002 to 2005 Medical Expenditure Panel Survey and used multivariate logistic regression models to estimate the likelihood of preventive care use among elderly persons in 4 living arrangements: living alone (38%), living with one's spouse only (52%), living with one's spouse and with one's adult offspring (5%), and living with one's adult offspring only (5%). Preventive care services included influenza vaccination, physical and dental checkup, and screenings for hypertension, cholesterol, and colorectal cancer.

RESULTS

After we controlled for age, gender, race, education, income, health insurance, comorbidities, self-reported health, physical function status, and residence location, we found that elderly persons living with a spouse only were more likely than were those living alone to obtain all preventive care services, except for hypertension screening. However, those living with their adult offspring were not more likely to obtain recommended preventive care compared with those living alone. These results did not change when the employment status and functional status of adult offspring were considered.

CONCLUSIONS

Interventions to improve preventive care use should target not only those elderly persons who live alone but also those living with adult offspring.

Access to health care for nonmetro and metro Latinos of Mexican origin in the United States

BACKGROUND

A growing number of Latinos are moving to nonmetro areas, but little research has examined how this trend might affect the Latino-disadvantage in access to healthcare.

OBJECTIVE

We investigate health care access disparities between non-Latino whites and Latinos of Mexican origin, and whether the disparities differ between metro and nonmetro areas.

METHODS

A series of logistic regression models provide insight on whether individuals have a usual source of care and whether they have had any physician visits in the past year. Our analyses focus on the interaction between Mexican origin descent and nonmetro residence.

SUBJECTS

Nationally representative data from the 2002-2003 Medical Expenditure Panel Survey are analyzed. The sample consists of working-aged adults age 18-64, yielding a sample size of 29,875.

RESULTS

The Mexican disadvantage in having a usual source of care is much greater among nonmetro residents than among those living in metro areas. The Mexican disadvantage in the likelihood of seeing a physician at least 1 time during the year does not differ across locations. Although general and ethnicity-specific predictors explain the disadvantage of Mexicans in having a usual source of care, they do not explain the added disadvantage of being Mexican and living in nonmetro areas.

CONCLUSIONS

This study identifies a new challenge to the goal of eliminating health care disparities in the United States. The Latino population living in nonmetro areas is growing, and our findings suggest that Latinos in nonmetro areas face barriers to having a usual source of care that are greater than those faced by Latinos in other areas.

Access to health care: does neighborhood residential instability matter?

Many Americans do not have access to adequate medical care. Previous research on this problem focuses primarily on individual-level determinants of access such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed medical care, however, has not received much attention. We address this gap in the literature by investigating the association between neighborhood residential instability and access to health care. Using individual-level data from the 2000 Medical Expenditure Panel Survey and block-group level data from the 2000 decennial census, we find that individuals who live in neighborhoods with high residential turnover have worse health care access than residents of other neighborhoods. This association persists even when the prevalence of poverty, the supply of health care, and a variety of individual characteristics are held constant. We offer explanations for these findings and suggest directions for future research.

Explaining racial and ethnic disparities in health care

OBJECTIVES

The substantial racial and ethnic disparities in access to and use of health services are well documented. A number of studies highlight factors such as health insurance coverage and socioeconomic differences that explain some of the differences between groups, but much remains unexplained. We build on this previous research by incorporating additional factors such as attitudes about health care and neighborhood characteristics, as well as separately analyzing different Hispanic subgroups.

METHODS

We use the Oaxaca-Blinder regression-based method to decompose differences among racial and ethnic groups in 3 measures related to access, quantifying the portion explained by each of a number of underlying characteristics and the differences that remain unexplained. We use data from the 2000 and 2001 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the noninstitutionalized U.S. population. We link these data to detailed neighborhood characteristics from the Census Bureau and local provider supply data from the Health Services Resource Administration (HRSA).

RESULTS

Consistent with earlier studies, we find insurance status and socioeconomic differences explain a significant part of the disparities. Additionally, neighborhood racial and ethnic composition account for a large portion of disparities in access, and language differences help explain observed disparities in the use-based access measure. However, much of the differences between racial and ethnic groups remain unexplained. We also found substantial variation in the level of disparities among different groups of Hispanics.

CONCLUSIONS

Researchers and policymakers may need to broaden the scope of factors they consider as barriers to access if the goal of eliminating disparities in health care is to be achieved.

Neighborhood socioeconomic disadvantage and access to health care

Most research on access to health care focuses on individual-level determinants such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed care, however, has not received much attention. We address this gap in the literature by examining how neighborhood socioeconomic disadvantage is associated with access to health care. We find that living in disadvantaged neighborhoods reduces the likelihood of having a usual source of care and of obtaining recommended preventive services, while it increases the likelihood of having unmet medical need. These associations are not explained by the supply of health care providers. Furthermore, though controlling for individual-level characteristics reduces the association between neighborhood disadvantage and access to health care, a significant association remains. This suggests that when individuals who are disadvantaged are concentrated into specific areas, disadvantage becomes an "emergent characteristic " of those areas that predicts the ability of residents to obtain health care.

County characteristics and racial and ethnic disparities in the use of preventive services

BACKGROUND

Studies examining predictors of preventive service utilization generally focus on individual characteristics and ignore the role of contextual variables. To help address this gap in the literature, the present study investigates whether county-level characteristics, such as racial and ethnic composition, are associated with the use of preventive services.

METHODS

Data from the Medical Expenditure Panel Survey and the Area Resource Files (1996-1998) are used to identify the individual- and county-level predictors of five types of preventive services (n = 49,063).

RESULTS

County racial or ethnic composition is associated with the utilization of certain preventive services, net of individual-level characteristics. Specifically, individuals in high percent Hispanic counties are more likely to report cholesterol screenings, while those in counties with more blacks are more likely to have regular mammograms. Moreover, county racial or ethnic composition modifies the relationship between individual race or ethnicity and preventive use. In particular, Hispanic individuals who reside in high percent black counties report higher levels of utilization for most preventive services compared to Hispanics living in other counties.

CONCLUSIONS

Physical and social environments are key determinants of health behaviors and outcomes. Future studies should take into account the racial or ethnic composition of an area and how this interacts with individual race or ethnicity when investigating predictors of preventive care use.

Has the increase in HMO enrollment within the Medicaid population changed the pattern of health service use and expenditures?

OBJECTIVE

To describe changes in health services use and expenditures within the Medicaid population between 1987 and 1997 and to estimate the extent to which the increase in Health Maintenance Organization (HMO) enrollment has influenced these changes.

SUBJECTS

Individuals under the age of 65 years in the 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey enrolled in Medicaid the entire year.

RESEARCH DESIGN

Using bivariate and multivariate techniques, we compared several measures of health services use and expenditures across three groups: (1) individuals enrolled in Medicaid for all of 1987; (2) individuals enrolled in Medicaid for all of 1997 but never enrolled in an HMO; and (3) individuals enrolled in Medicaid for all of 1997 and enrolled in an HMO for at least part of the year.

RESULTS

Medicaid enrollees in 1997 differ little from Medicaid recipients in 1987 with respect to use and expenditures. Modest but statistically significant differences emerge, however, when a distinction is made between HMO enrollees and non-HMO enrollees in 1997. Specifically, 1997 Medicaid HMO enrollees have significantly fewer hospital visits than 1987 Medicaid enrollees and spend significantly less on health services than 1997 non-HMO enrollees.

CONCLUSIONS

Our findings suggest that the increase in HMO enrollment may have held down use and expenditures to rates modestly lower than what would have been expected had HMO enrollment not increased.

Health insurance and family structure: the case of adolescents in skipped-generation families

Since 1970, both the number and proportion of children being parented by a grandparent without the help of a parent has increased substantially. The increase in skipped-generation households has generated much concern from policy makers because such households are, on average, disadvantaged compared with most other household types. One important challenge facing grandparents with parenting responsibilities is securing health insurance for their dependent grandchildren. In this study, the authors investigate the extent to which grandparents raising their grandchildren were able to secure health insurance for their dependent grandchildren. They find that adolescents living in skipped-generation families in 1995 were more often uninsured, more often publicly insured, and less often privately insured compared with adolescents in other family types. Even after controlling for income, work status, and education, adolescents in skipped-generation families were still more likely to have public insurance and less likely to have private insurance compared with other adolescents.

The influence of parental separation on smoking initiation in adolescents

Most adult smokers start smoking when they are adolescents and, the prevalence of smoking declines less than other unhealthy behaviors as people mature. Understanding why adolescents start smoking is, therefore, key to developing effective policy aimed at lowering the prevalence of smoking in both children and adults. In this study, I suggest that parental separation is one possible risk factor for smoking initiation. I use a nationally representative sample of American adolescents interviewed at two points in time to examine the influence of parental separation on smoking initiation. Two questions are addressed. First, is there a relationship between parental separation and the likelihood that an adolescent will initiate smoking? Second, if there is a relationship, through what factors does parental separation operate to influence the initiation of smoking in adolescents? My findings suggest that parental separation increases the likelihood that adolescents will start smoking. It does so in part by raising depressive symptoms and rebelliousness in adolescents. Despite the significance of these indirect effects, however, the bulk of the effect of parental separation on smoking initiation is direct.

Exposure, resistance, and recovery: a three-dimensional framework for the study of mortality from infectious disease

It has been suggested by several scholars that debates surrounding the study of mortality could benefit from a framework that integrates social and economic factors with the biological mechanisms of illness and death (Johannson and Mosk, Popul. Stud. 41 (1987) 207-236; Mosley, International Population Conference, Vol. 2, Florence, IUSSP, Liege, 1985. pp. 189-203; Mosley and Chen, in W. H. Mosley, L. C. Chen (Eds.), Child Survival: Strategies for Research, Population Council, New York, 1984, pp. 25-45; Murray and Chen, Soc. Sci. Med. 36(2) (1993) 143-155; Ruzicka, International Population Conference, Vol. 2, Florence, IUSSP, Liege, 1985, pp. 185-187). In this paper, I present a conceptual framework aimed at doing this for infectious disease mortality. The framework is built around three proximate processes: (1) exposure to potentially lethal pathogens, (2) resistance to disease pathogens after exposure, and (3) recovery from disease episodes after contraction. I apply this conceptual framework to morbidity and mortality from cholera across 41 less developed nations.