Has public health insurance for older children reduced disparities in access to care and health outcomes?

This paper investigates the effects of expanding public health insurance eligibility for older children. Using data from the National Health Interview Surveys from 1986 to 2005, we first show that although income continues to be an important predictor of children's health status, the importance of income for predicting health has fallen for children 9-17 in recent years. We then investigate the extent to which the dramatic expansions in public health insurance coverage for these children in the past decade are responsible for the decline in the importance of income. We find that while eligibility for public health insurance unambiguously improves current utilization of preventive care, it has little effect on current health status. However, we find some evidence that Medicaid eligibility in early childhood has positive effects on future health. This may indicate that adequate medical care early on puts children on a better health trajectory, resulting in better health as they grow.     

Value for money? An examination of the relationship between need and cost in intellectual disability services

The recent economic crisis along with changing demographic trends has stimulated an increased interest in the value obtained from social care expenditure so as to ensure the sustainability of systems in the future. In Ireland, the Department of Health, further to a recent review of its disability services, commited to a new approach that will reshape and redesign its service provision. It specifically outlined a reorganisation of financing services, from a model of prospective block grant funding to a system of individualised budgeting based on an assessment of need. This paper examines the relationship between need, service utilisation and cost for high‐cost users of adult intellectual disability residential services in an Irish county under the current model of block grant financing. The analysis reported is based on primary data collected from 68 high‐cost users of adult intellectual disability residential services in an Irish county in 2013. Statistical analysis was performed to identify the relationship between need and cost, and also to examine the variations in the cost of support between the service provider organisations. Our analysis determined an association between need and cost, with poorer levels of psychological well‐being related to higher costs. However, the study found no evident relationship between staff/client ratios, the numbers of staff engaged at the residential units and need. An examination of cost variations between the service provider organisations revealed that agency status; service unit size; client and staff characteristics all contributed to variations in the cost of care. This study supports the development of a national resource allocation framework as being fundamental to the equitable and transparent distribution of scarce resources, as recommended by the Department of Health in Ireland.     

Stability of children’s insurance coverage and implications for access to care: evidence from the Survey of Income and Program Participation

Even as the number of children with health insurance has increased, coverage transitions—movement into and out of coverage and between public and private insurance—have become more common. Using data from 1996 to 2005, we examine whether insurance instability has implications for access to primary care. Because unobserved factors related to parental behavior and child health may affect both the stability of coverage and utilization, we estimate the relationship between insurance and the probability that a child has at least one physician visit per year using a model that includes child fixed effects to account for unobserved heterogeneity. Although we find that unobserved heterogeneity is an important factor influencing cross-sectional correlations, conditioning on child fixed effects we find a statistically and economically significant relationship between insurance coverage stability and access to care. Children who have part-year public or private insurance are more likely to have at least one doctor’s visit than children who are uninsured for a full year, but less likely than children with full-year coverage. We find comparable effects for public and private insurance. Although cross-sectional analyses suggest that transitions directly between public and private insurance are associated with lower rates of utilization, the evidence of such an effect is much weaker when we condition on child fixed effects.     

Does Medicaid managed care affect access to care for the uninsured?

This study investigates whether the implementation of Medicaid managed care from 1994 to 2001 was associated with changes in access to care for the uninsured. We used regression analysis to examine relationships between changes in county-level Medicaid managed care activity over time and changes in four measures of perceived access to care. After we controlled for sex, race, ethnicity, poverty, age, health, and education and included county fixed effects to account for unobserved county characteristics that are potentially associated with the implementation of Medicaid managed care and outcome measures, we found that Medicaid managed care has had no consistent effect on access.     

Value for the Money Spent? Exploring the Relationship Between Expenditures,Insurance Adequacy,and Access to Care for Publicly Insured Children

To examine whether the frequency of four screening tests during prenatal care conforms to evidence of effectiveness. We estimated rates of urine culture, anemia screening, oral glucose tolerance test (OGTT), and urinalysis during prenatal care. To do this, we used national probability samples of office visits to physicians (National Ambulatory Medical Care Survey) and to hospital outpatient departments (National Hospital Ambulatory Medical Care Survey) from 2001 to 2006. We compare observed rates to recommendations from the U.S. Preventive Services Task Force (USPSTF). On average, women received a urine culture in less than half of pregnancies. Women received just over one anemia screening on average per pregnancy. From 2001–2003, women received an average of 5.6 urinalyses per pregnancy; the average dropped to 4.3 urinalyses per pregnancy in 2004–2006. On average, women received just under one OGTT per pregnancy. Minorities and older women tend to get more anemia screenings, urine cultures, and OGTTs than white women and younger women. Compared to USPSTF recommendations, too few women are receiving a urine culture during prenatal care. In contrast, women receive far too many urinalyses, but the rate appears to be falling. Anemia screening conforms closely to recommendations. The USPSTF does not recommend for or against universal diabetes screening using OGTT. Women appear to receive OGTT routinely.     

Why is less money spent on health care for the elderly than for the rest of the population? Health care rationing in German hospitals

The consequences of population ageing for the public health care system and health care costs may be less severe than is commonly assumed. Hospital discharge data from Germany's largest health insurer (AOK) show that the cost of caring for patients during their last year of life makes up a large part of total health expenditures. And this last year of life is less costly if patients die at an advanced age. As a multivariate analysis reveals, oldest old patients as a rule receive less costly treatment than younger patients for the same illness. Moreover, this pattern is more pronounced for elderly women than for elderly men. These findings suggest that health care is informally rationed according to the age and sex of the patient. The data also indicate that there may be more age-related rationing going on in Germany than in the United States. Future research should investigate the national, institutional, and individual factors behind health care rationing. In this paper, I discuss the physician's professional decision as one plausible determinant.     

Does free complementary health insurance help the poor to access health care? Evidence from France

The French government introduced a 'free complementary health insurance plan' in 2000, which covers most of the out-of-pocket payments faced by the poorest 10% of French residents. This plan was designed to help the non-elderly poor to access health care. To assess the impact of the introduction of the plan on its beneficiaries, we use a longitudinal data set to compare, for the same individual, the evolution of his/her expenditures before-and-after enrollment in the plan. This before-and-after analysis allows us to remove most of the spuriousness due to individual heterogeneity. We also use information on past coverage in a difference-in-difference analysis to evaluate the impact of specific benefits associated with the plan. We attempt at controlling for changes other than enrollment through a difference-in-difference analysis within the eligible (rather than enrolled) population. Our main result is the plan's lack of an overall effect on utilization. This result is likely attributable to the fact that those who were enrolled automatically in the free plan (the majority of enrollees), already benefited from a relatively generous plan. The significant effect among those who enrolled voluntarily in the free plan was likely driven by those with no previous complementary coverage.     

Value for money? A contingent valuation study of the optimal size of the Swedish health care budget

The contingent valuation method has been developed in the environmental field to measure the willingness to pay for environmental changes using survey methods. In this exploratory study the contingent valuation method was used to analyse how much individuals are willing to spend in total in the form of taxes for health care in Sweden, i.e. to analyse the optimal size of the 'health care budget' in Sweden. A binary contingent valuation question was included in a telephone survey of a random sample of 1260 households in Sweden. With a conservative interpretation of the data the result shows that 50% of the respondents would accept an increased tax payment to health care of about SEK 60 per month ($1 = SEK 8). It is concluded that the results indicate that the population overall thinks that the current spending on health care in Sweden is on a reasonable level. There seems to be a willingness to increase the tax payments somewhat, but major increases does not seem acceptable to a majority of the population.     

Information and access to health care: is there a role for trust?

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure.     

Insurance coverage and access to care for workers with disabilities, 2001–2017

BackgroundWorkers with disabilities have different options than their peers for obtaining health insurance, and face unique barriers in accessing care. The Patient Protection and Affordable Care Act (ACA) led to sweeping changes in the availability and affordability of health insurance in the United States beginning in 2010, and may have had important effects for workers with disabilities.Objective/HypothesisDocument how the ACA changed insurance coverage and access to care for workers with disabilities, and compare those changes to changes among other groups.MethodsWe document health insurance coverage and access to care among workers with disabilities using the 2001–2017 National Health Interview Survey.ResultsThe share of insured workers with disabilities increased from 79.9% in 2009 to 87.8% in 2017. This gain resulted from an 11 percentage point (pp) increase in the share with Medicaid coverage in 2014–2017 compared with 2001–2009 and a 5 pp increase in privately purchased coverage over those periods. These were accompanied by an 11 pp decline in the share with employer-sponsored coverage. Despite coverage gains, cost-related barriers to accessing medical care did not change much after the ACA, for any group. Workers with disabilities experienced an increase in structural access barriers, from 18.4% before the ACA to 24.8% after.ConclusionsThe gain in insurance coverage for workers with disabilities is an important benefit of the ACA, but more investigation and monitoring should be considered to understand whether such coverage will translate into improvements in access to needed health care.     

Healthy,wealthy and insured? The role of self‐assessed health in the demand for private health insurance

Both adverse selection and moral hazard models predict a positive relationship between risk and insurance; yet the most common finding in empirical studies of insurance is that of a negative correlation. In this paper, we investigate the relationship between ex ante risk and private health insurance using Australian data. The institutional features of the Australian system make the effects of asymmetric information more readily identifiable than in most other countries. We find a strong positive association between self-assessed health and private health cover. By applying the Lokshin and Ravallion (J. Econ. Behav. Organ 2005; 56:141-172) technique we identify the factors responsible for this result and recover the conventional negative relationship predicted by adverse selection when using more objective indicators of health. Our results also provide support for the hypothesis that self-assessed health captures individual traits not necessarily related to risk of health expenditures, in particular, attitudes towards risk. Specifically, we find that those persons who engage in risk-taking behaviours are simultaneously less likely to be in good health and less likely to buy insurance.     

Running to the Store? The relationship between neighborhood environments and the risk of obesity

We expand the search for modifiable features of neighborhood environments that alter obesity risk in two ways. First, we examine residents' access to neighborhood retail food options in combination with neighborhood features that facilitate physical activity. Second, we evaluate neighborhood features for both low income and non-low income neighborhoods (bottom quartile of median neighborhood income versus the top three quartiles).Our analyses use data from the Utah Population Database merged with U.S. Census data and Dun & Bradstreet business data for Salt Lake County, Utah. Linear regressions for BMI and logistic regressions for the likelihood of being obese are estimated using various measures of the individual's neighborhood food options and walkability features.As expected, walkability indicators of older neighborhoods and neighborhoods where a higher fraction of the population walks to work is related to a lower BMI/obesity risk, although the strength of the effects varies by neighborhood income. Surprisingly, the walkability indicator of neighborhoods with higher intersection density was linked to higher BMI/obesity risk. The expected inverse relationship between the walkability indicator of population density and BMI/obesity risk is found only in low income neighborhoods.We find a strong association between neighborhood retail food options and BMI/obesity risk with the magnitude of the effects again varying by neighborhood income. For individuals living in non-low income neighborhoods, having one or more convenience stores, full-service restaurants, or fast food restaurants is associated with reduced BMI/obesity risk, compared to having no neighborhood food outlets. The presence of at least one healthy grocery option in low income neighborhoods is also associated with a reduction in BMI/obesity risk relative to no food outlets. Finally, multiple food options within a neighborhood reduce BMI/obesity risk, relative to no food options, for individuals living in either low-income or non-low neighborhoods.     

Selling open access health care delivery to patients and administrators: what's the hook?

A new concept in health care delivery involves the use of Open Access Scheduling for patients. In an attempt to manage spiraling medical costs and patient care demands many medical practices and managed care organizations are looking for alternative delivery models for health care. Open Access Scheduling has been garnering many advocates and converts from past traditional medical service delivery models. Unfortunately, due to its limited penetration into the medical community, little of Open Access' essential characteristics are generally understood. This paper looks at Open Access from the perspectives of: patients, medical administrators, office staff and providers. We discuss the tenets of Open Access, the benefits from its use, its challenges, and the steps necessary to initiate this type of service delivery.     

Can the Veterans Affairs health care system continue to care for the poor and vulnerable?

Can the Veterans Affairs (VA) health care system, long an important part of the safety net for disabled and poor veterans, survive the loss of World War II veterans--once its largest constituency and still its most important advocates? A recent shift in emphasis from acute hospital-based care to care of chronic illness in outpatient settings, as well as changes in eligibility allowing many more nonpoor and nondisabled veterans into the VA system, will be key determinants of long-term survivability. Although allowing less needy veterans into the system runs the risk of diluting services to those most in need, the long-run effect may be to increase support among a larger and younger group of veterans, thereby enhancing political clout and ensuring survivability. It may be that the best way to maintain the safety net for veterans is to continue to cast it more widely.     

Hope for the uninsured? HHS proposes a series of initiatives to expand coverage,broaden access for the 41 million Americans without health insurance

It's no secret there's a deepening fear in the U.S. as more and more Americans go without health insurance. But the problem came into sharper focus last week as HHS proposed an array of initiatives to expand coverage and widen access. And in Utah, a Medicaid initiative offers ideas on covering the uninsured. Richard Kinnersley, left, president of the Utah Hospitals and Health Systems Association, praises that plan.     

Inequalities in access to health care services and utilization for the elderly in São Paulo, Brazil

OBJECTIVE: To describe factors associated to inequalities in access to health care services and utilization for the elderly. METHODS: Study part of the Health, Well-being and Aging in Latin America and the Caribbean ("SABE") Survey that included 2,143 elderly individuals aged 60 or older in the city of S?o Paulo, southeastern Brazil, in 2000. A two-step sampling procedure with probability proportional to size was carried out using census tracts with replacement. To achieve the desired number of respondents aged 75 or older, additional households close to the selected census tracts were sampled. Access to health services and utilization were measured for outpatient and hospital services during a 4-month period prior to the interview, and correlated to factors related to ability, need and predisposition (total income, schooling, health insurance, reported medical condition, self-perception, gender and age).Multivariate logistic regression was performed in the analysis. RESULTS: Of all respondents, 4.7% reported being hospitalized and 64.4% seeking outpatient care in the four months prior to the study. As for public outpatient care provided, 24.7% were in hospital clinics and 24.1% in other public outpatient services. As for private care, 14.5% received care in hospitals and 33.7% in health clinics. The multivariate analysis showed an association between health service utilization and sex, medical condition, self-perceived health, income, schooling, and health insurance. However, an inverse effect was found for the variable "schooling". CONCLUSIONS: The study results show inequalities in access to health services and utilization as well as a deficient health care system. Public policies should take into account the specific needs of the elderly population to facilitate access to health care services and reduce inequalities.     

Does size matter? The relationship between volume and outcome in the care of major trauma

OBJECTIVES: To investigate the relationship between case volume and outcome for major trauma patients. METHODS: Prospective follow-up study of all major trauma patients (with injury severity score >15) arriving alive, with no invariably fatal injury, at 14 English emergency departments between 1990 and 1993. Using the stratified W statistic, an age and severity adjusted measure of outcome, the relationship between volume of cases and outcome was initially examined using the Spearman correlation coefficient. Multiple regression analysis was used to explore further the relationship, after adjustment for hospital-level characteristics. RESULTS: The smallest department saw five major trauma cases each year, the largest saw 96. The results of the initial correlation analyses indicated that there was little evidence that outcome improved with increasing volumes for all major trauma (rho(s) = 0.12, 95% confidence interval [CI]: -0.36 to 0.55) nor for the cases presenting out-of-hours (rho(s) = 0.30, 95% CI: -0.19 to 0.67). However, there was evidence that patients with multiple injury (rho(s) = 0.65, 95% CI: 0.27 to 0.86) and those with severe head injuries (rho(s) = 0.52, 95% CI: 0.08 to 0.79) did better in high volume departments. This pattern, of a positive relationship for more complex cases was also in evidence from the results of the multiple regression analyses and, in particular, for patients with multiple injuries, was stable over time. CONCLUSIONS: While there was little evidence that all patients with major trauma do better in higher volume departments, there was evidence that patients with complex needs, such as the multiple injured or those with head injuries, had better outcomes.     

Can the health insurance reforms stop an increase in medical expenditures for middle- and old-aged persons in Japan?

Using two-period panel data from the Nippon Life Insurance Research Institute, this paper tests the hypothesis that an increase in the self-pay ratio of medical expenditures associated with the Japanese health insurance reforms of April 2003 reduced household medical expenditures. We find that the increase in the self-pay ratio had a positive but insignificant effect on the share of medical expenses in household expenditure. However, when we employ the data as repeated cross-sectional observations to increase the sample size, the increase in the self-pay ratio has a significantly positive effect on the share of medical expenditures. This provides corroborating evidence that middle- and old-aged persons were unable to reduce their demand for medical services with the increase in the self-pay ratio. An additional finding is that medical services are a necessary good, particularly for those aged 61 years or older and those with medical expenditures accounting for a relatively high share of medical expenditures in high household expenditure.