Life transitions and health insurance coverage of the near elderly

OBJECTIVES: This study addresses three issues. (1) What are demographic wealth, employment, and health characteristics of near-elderly persons losing or acquiring health insurance coverage? Specifically, (2) what are the effects of life transitions, including changes in employment status, health, and marital status? (3) To what extent do public policies protect such persons against coverage loss, including various state policies recently implemented to increase access to insurance? METHODS: The authors used the 1992 and 1994 waves of the Health and Retirement Study to analyze coverage among adults aged 51 to 64 years. RESULTS: One in five near-elderly persons experienced a change in insurance coverage from 1992 to 1994. Yet, there was no significant change in the mix of coverage as those losing one form of coverage were replaced by others acquiring similar coverage. CONCLUSIONS: Individuals whose health deteriorated significantly were not more likely than others to suffer a subsequent loss of coverage, due to substitution of retiree or individual coverage for those losing private coverage and acquisition of Medicaid and Medicare coverage for one in five uninsured. State policies to increase access to private health insurance generally did not prevent individuals from losing coverage or allow the uninsured to gain coverage. Major determinants of the probability of being insured were education, employment status of person and spouse, and work disability status. Other measures of health and functional status did not affect the probability of being insured, but had important impacts on the probability of having public coverage, conditional on being insured.     

Insurance matters for low-income adults: results from a five-state survey

Using survey data from 2,000 low-income adult respondents in each of five states, this DataWatch assesses how uninsured, low-income adults differ from low-income adults who have public or private insurance and how Medicaid expansions have affected insurance coverage patterns across states with different eligibility policies. Findings show that the proportion of low-income uninsured adults is two to three times higher in states that have not expanded Medicaid eligibility beyond relatively low welfare levels. Compared with persons who have either Medicaid or private insurance, uninsured persons report more difficulties getting needed care, are less likely to have a regular provider, and rate the care they do receive as lower quality.     

Discrepancies in employer-sponsored health insurance among Hispanics, blacks, and whites: the effects of sociodemographic and employment factors

Using a nationally representative sample of employed adults from the 1987 National Medical Expenditure Survey (NMES), this research explores differences in the incidence and predictors of employer-sponsored health insurance among Hispanics, blacks, and whites. The data suggest that: 1) whites are most likely, and Hispanics are least likely, to have employer-sponsored medical insurance in their own name, or in the name of another individual; 2) Hispanics are most likely, and whites are least likely, to be completely uninsured; and 3) the factors which increase the odds of receiving employer-sponsored coverage in one's own name are relatively similar across racial groups, though they differ substantially in magnitude.     

Effects of state reforms on health insurance coverage of adults

States have tried a number of strategies to reduce the growing number of uninsured people. These include Medicaid expansions and various insurance reforms, such as low-cost plans, subsidized insurance products, risk pooling, open enrollment and continuity of coverage requirements, and community rating. Using data from 1989 to 1994, we examine the impact of such policies on health insurance coverage for adults. We find that few state policies have succeeded in increasing health insurance coverage. For those that work, impacts are very modest or are accompanied by adverse effects such as crowdout. Implementing effective state policies to reduce the number of uninsured remains a great challenge.     

Endometrial cytology in postmenopausal hormone replacement therapy

INTRODUCTION: The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competitive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. METHODS: A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. RESULTS: California's HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%-3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%-45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. CONCLUSION: For the majority of California's PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.     

Lipid disorders in NIDDM: implications for treatment

BACKGROUND: In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays. METHODS: All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling. RESULTS: Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage. CONCLUSIONS: Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.     

Individuals with COBRA coverage, 1994-1995. Consolidated Omnibus Budget Reconciliation Act

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) coverage can be considered advantageous for most workers. Although an employee can be required to pay 102 percent of the premium for COBRA coverage, workers can usually realize significant savings compared to purchasing the equivalent health insurance policy in the private market. Many employers consider COBRA to be a costly mandate for three reasons. First, premiums collected from COBRA beneficiaries typically do not cover the costs of the health care services rendered. Second, COBRA imposes an additional administrative cost on employers. Third, many employers view the penalties for noncompliance as excessively large. We examined data from the 1993 panel of the Survey of Income and Program Participation (SIPP) to gain a better understanding of the COBRA population. The COBRA population was found to be much older than the population of individuals with employment-based coverage through their current employer. COBRA beneficiaries were also more likely than individuals with coverage through a current employer to be male, married, white and to have a graduate school education. They were also less likely to be working and were more likely to have retirement income. Any attempt to expand COBRA coverage, either through subsidies or by allowing workers to choose from plans with lower premiums, will likely result in increased employer health care costs. Survey data indicate that the primary issue concerning COBRA is its impact on claims experience and administrative costs on active employees, employers and COBRA beneficiaries. If the cost issues are not addressed with future COBRA expansions, employers may consider various alternatives to reduce, shift or eliminate the impact of this increased cost.     

Regulation of uterine immune function by progesterone--lessons from the sheep

Analyzing cross-sectional data from the National Medical Expenditure Survey (NMES), we find that the predicted probability of private insurance coverage for low-income individuals as a group fell dramatically from 1977 to 1987. The results of a decompositional technique show that the relationship between full-time employment and private insurance has weakened over the period for low-income females, but has strengthened for males in this group. While it appears that low-income females benefit from part-time employment relative to their unemployed cohorts, no discernible difference is found in the likelihood of being covered by private insurance for part-time and unemployed males. Finally, evidence suggesting a weakening over time in the relationship between part-time employment and private insurance coverage is found among middle-income females and high-income males. From a policy perspective, passage of the Health Insurance Portability and Accountability Act of 1996 has taken an important first step in attempting to lower the number of uninsured, especially among full-time workers. Our findings, however, suggest that this legislation may be too limited in scope to effectively reach part-time workers presently uninsured.     

Health care triage alternatives and the influence of health insurance, education and race

The relationship between one of Andersen's enabling factors, health insurance status and the choice of a pharmacist as the initial contact in the health care system was examined via telephone surveys. Eighty-seven percent of the sample reported having some form of health insurance. Of all intended health care provider contacts, pharmacists were selected as the initial contact 21% of the time. Logistic regression identified insurance status, education and race as significant (alpha < 0.05) covariates in the model. The odds ratios generated from the logit model indicated that non-whites, persons with less education and no health insurance were more likely to select a pharmacist for triage. The study concluded that uninsured persons were nearly twice as likely to seek pharmacist triage than insured individuals. Pharmacists may be filling an important triage gap for individuals who have limited financial access to traditional sources of physician care.     

Access to health care. Part 2: Working-age adults

OBJECTIVES: This report presents data on access to health care for U.S. working-age adults, 18-64 years old. Access indicators are examined by selected sociodemographic characteristics including sex, age, race and/or ethnicity, place of residence, employment status, income, health status, and health insurance status. METHODS: Data are from the 1993 Access to Care and 1993 Health Insurance Surveys of the National Health Interview Survey (NHIS), a continuing household survey of the civilian noninstitutionalized population of the United States. The sample contained 61,287 persons in 24,071 households. RESULTS: In 1993, approximately 3 out of 4 working-age adults had a regular source of medical care. Nine out of 10 adults with health insurance had a regular source of care compared with 6 out of 10 adults without health insurance. For adults with a regular source of care, 86 percent received care in a private doctor's office, 9 percent in a clinic, and 2 percent in a hospital emergency room. The two main reasons given for not having a regular source of care were "do not need a doctor" (49 percent), and "no insurance can't afford it" (22 percent). Persons in the highest income group were more likely to report no need for a doctor (59 percent) than persons in the lowest income group (35 percent). About 40 percent of uninsured persons and 16 percent of insured persons reported an unmet medical need. CONCLUSIONS: Health insurance plays a key role in the access to medical care services. Persons who are uninsured or have low incomes are at the greatest risk of having unmet medical needs.     

Primary sinonasal mucosal melanoma: three different therapeutic approaches to inoperable local disease or recurrence and a review of the literature

Neonatal tetanus is still an important public health problem in both urban and rural Bangladesh, with an estimated 41,000 cases occurring annually. This article analyses the coverage of tetanus toxoid (TT) immunizations among women of reproductive age in Zone 3 of Dhaka City in 1995. Although 85% of women with a child under 1 year of age had received two TT immunizations, only 11% of women of reproductive age had obtained the complete series of five TT immunizations and only 52% of women of reproductive age had received one or more TT immunizations. Access to TT immunization, as defined by having had at least one such immunization, was lower among women aged over 30 years and also among those aged under 20 years, especially those who were not yet married or who had not yet become pregnant. Characteristics associated with TT immunization status included the following: educational level of the woman, distance from the nearest immunization centre, and level of contact with family planning field workers. Additional characteristics that influenced women's TT immunization status included age, marital and working status, recency of migration from rural to urban area, and number of children. The relationships were complex and varied depending on the number of TT immunizations received (one or two) and on the type of analysis being carried out (bivariate or multivariate). The findings point to the need for a broad-based campaign to promote access to TT immunization as well as to promote the completion of all five TT doses in Bangladesh. Reducing missed opportunities for promotion of immunization as well as targeting home visitation of women in need of additional immunizations constitute further approaches to improving coverage. Although TT coverage rates were only marginally lower among women in slum households, such women were more likely than those in non-slum households to be pregnant and hence more likely to bear a baby at risk of neonatal tetanus. Furthermore, the environment of slum households, where deliveries normally take place, is more conducive to the development of neonatal tetanus among unprotected neonates; a strategy of focusing on slum households is therefore also needed.     

Managed healthcare consumer protection initiatives

This three part series on health legislation describes the policy shift toward regulating the private healthcare system to ensure adequate consumer protection and access to health insurance. Still burning from the failed 1993-1994 healthcare reform effort, Congress and the White House are looking only for incremental policies necessary to reduce the federal deficit and protect the public white the private healthcare system continues to undergo major transformation. In this series, the author discusses Medicare, Medicaid, and other federal program revisions: consumer protection legislation aimed at unacceptable managed care practices: and incremental health insurance proposals aimed toward segments of the uninsured.     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

A re-examination of widowhood and morale

Previous research has suggested widowed status to be associated with lower morale or life satisfaction. The effects of marital status on morale relative to five covariates (health, income, age, family interaction, and employment status) were examined with 232 widowed and 363 married women aged 45-74, drawn in a multistage stratified area probability sample of Los Angeles County. Analysis of covariance was utilized with a six-item, factor analyzed measure of morale. Parallel analyses were performed for each of three ethnic groups (blacks, Mexican-American, and white) to examine specific ethnic patterns. In the total sample, poor health was associated with significantly lower morale among widowed than among married women. The analysis with age showed the widowed group catching up and surpassing their married peers on morale at higher ages. Controlling for income and employment status eliminated differences between the marital status groups on morale scores. Higher family interaction was positively associated with morale in both groups, but married women were consistently higher on morale regardless of level of interaction. Most ethnic differences were not significant, but family interaction appeared to be crucial among Mexican-American widows. The findings suggest that lower morale scores found among the widowed may be partly attributable to other factors commonly associated with this status and not due to the role of widowhood per se.     

Health care reform is coming.

During my career in Congress, we have achieved some success in expanding health insurance coverage and keeping services affordable, but the problem of 46 million uninsured and 25 million underinsured must be addressed. In February 2009, I introduced the Healthy Americans Act (S. 391/H.R. 1321; Wyden, 2009), a comprehensive bipartisan health care reform bill that covers all Americans without breaking the bank, by weaving together the Democratic idea that we need to give every single person in the country health care coverage and the Republican belief in a private-market approach. This bill would favorably affect providers in nonprofit institutions, public institutions, and school systems, by ending cost shifting from public program underpayments to the privately insured. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anger, aggression, and violence in love triangles

This paper presents a longitudinal examination of the effect of employment transitions on the psychological distress of 398 single and 454 married mothers. Our analyses reveal that the effects of employment transitions differ for single and married mothers. Among women who left their jobs during the course of this study, we find a significant increase in distress among single mothers but no change in distress among married mothers. Transitions out of employment among single mothers produce increases in financial strain that result in declines in levels of self-esteem and mastery which, in turn, manifest themselves in higher levels of psychological distress. When we examine the effects of transitions into paid work, there are surprisingly few effects on mothers' levels of distress. For single mothers, taking a job for pay offers no significant reduction in their feelings of distress. Among married mothers, transitions into employment are associated with declines in distress, but these declines are offset by the distressful consequences of increases in caregiving strain. Thus, the effects of employment transitions on distress are a function of the differential impact of changes in stressors and psychosocial resources among single and married mothers as well as variations in the economic context and meanings of employment transitions. Movements into or out of employment do not offer the same opportunities and benefits or engender the same costs for single and married mothers. Our results also highlight the different policy implications that emerge from a consideration of longitudinal as opposed to cross-sectional analyses of these issues.     

Private health insurance and veterans use of Veterans Affairs care. RATE Project Committee. Rate Alternative Technical Evaluation

OBJECTIVES: This study examined the effect of private health insurance on the use of medical, surgical, psychiatric, and addiction services for patients eligible for publicly supported care. METHODS: The authors assembled administrative databases describing 350,000 noninstitutionalized veterans who had been discharged from a Veterans Affairs (VA) inpatient medicine or surgery bed section during a 1-year period. Patient use of care was followed for 1 year after the index discharge. Patient insurance information came from Medical Care Cost Recovery Billing and Collection files obtained separately from each of 162 VA Medical Centers. Distances between VA and non-VA sources of care were estimated from the Health Care Financing Administration's Hospital Distance File. RESULTS: Insured patients were less likely to seek surgical care but were 12 times (65 years of age and older) and 73 times (63 years of age and younger) more likely to initiate outpatient medical visits than were their counterparts, adjusted for patient demographic, diagnostic, and index facility characteristics. Patients who had private health insurance also were 3.4 (> or = 65) and 2.6 (< or = 64) times less likely to use VA surgical care in response to changes in available surgical staff-to-patient ratios than were their uninsured counterparts. CONCLUSIONS: Private health insurance may substitute (reduce) or complement (increase) the continued use of publicly supported health care services, depending on patient age, care setting, and service type.     

A clinical trial of a financial incentive to go to the tuberculosis clinic for isoniazid after release from jail

PURPOSE: To assess the effect of insurance status on the probability of admission and subsequent health status of patients presenting to emergency departments. SUBJECTS AND METHODS: We performed a prospective cohort study of patients with common medical problems at five urban, academic hospital emergency departments in Boston and Cambridge, Massachusetts. The outcome measure for the study was admission to the hospital from the emergency department and functional health status at baseline and follow-up. RESULTS: During a 1-month period, 2,562 patients younger than 65 years of age presented with either abdominal pain (52%), chest pain (19%) or shortness of breath (29%). Of the 1,368 patients eligible for questionnaire, 1,162 (85%) completed baseline questionnaires, and of these, 964 (83%) completed telephone follow-up interviews 10 days later. Fifteen percent of patients were uninsured and 34% were admitted to the hospital from the emergency department. Uninsured patients were significantly less likely than insured patients to be admitted, both when adjusting for urgency, chief complaint, age, gender and hospital (odds ratio = 0.5, 95% confidence interval 0.3 to 0.7), and when additionally adjusting for comorbid conditions, lack of a regular physician, income, employment status, education and race (odds ratio = 0.4, 95% confidence interval 0.2 to 0.8). However, there were no differences in adjusted functional health status between admitted and nonadmitted patients by insurance status, either at baseline or at 10-day follow-up. CONCLUSIONS: Uninsured patients with one of three common chief complaints appear to be less frequently admitted to the hospital than are insured patients, although health status does not appear to be affected. Whether these results reflect underutilization among uninsured patients or overutilization among insured patients remains to be determined.