Massachusetts reform plus President Bush's tax credits: a national model?

The Massachusetts health reform offers an important opportunity for a new federal-state strategy to cover the uninsured. President George Bush's proposed health insurance tax credits could be added to the Massachusetts health reform. The combined plan would include Medicaid expansions; offer workers affordable coverage through competitive insurance markets; and provide federal, state, employer, and individual financing. Many other states might be interested in similar federal-state partnerships for the forty-five million uninsured Americans. Ending the national impasse on coverage needs this kind of bold initiative.     

Administrative waste in the U.S. health care system in 2003: the cost to the nation, the states, and the District of Columbia, with state-specific estimates of potential savings.

This report provides nationwide and state-specific estimates of U.S. health care administration spending and potential savings in 2003 were the United States to institute a Canadian-style national health insurance system. The United States wastes more on health care bureaucracy than it would cost to provide health care to all its uninsured. Administrative expenses will consume at least dollar 399.4 billion of a total health expenditure of dollar 1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately dollar 286.0 billion in 2003, dollar 6,940 for each of the 41.2 million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage. The cost of excess health bureaucracy in individual states is equally striking. For example, Massachusetts, with 560,000 uninsured state residents, could save about dollar 8,556 million in 2003 (dollar 16,453 per uninsured resident of that state) if it streamlined administration to Canadian levels. New Mexico, with 373,000 uninsured, could save dollar 1,500 million on health bureaucracy (dollar 4,022 per uninsured resident). Only a single-payer national health insurance system could garner these massive administrative savings, allowing universal coverage without any increase in total health spending. Because incremental reforms necessarily preserve the current fragmented and duplicative payment structure, they cannot achieve significant bureaucratic savings.     

California's role in ensuring that the potential of health reform becomes reality

The fifty states will play a critical role in implementing the Affordable Care Act, and California is one of the states at the forefront of reform. The act can provide coverage to millions of currently uninsured Californians and offers important benefits in terms of more-affordable coverage, improved access to services, and better health outcomes. As the paper by Peter Long and Jonathan Gruber in this issue of Health Affairs notes, the ultimate effects of health reform in California will be influenced by the policy and program decisions that state lawmakers and administrators make during the next three years. Key issues include revamping cumbersome eligibility determination and enrollment processes that could prevent rapid enrollment in expanded public health insurance--but also affording that expansion in the face of large state budget deficits. California policy makers need to move thoughtfully and strategically to ensure that the potential of federal health reform becomes a reality for state residents.     

Projected COVID-19 epidemic in the United States in the context of the effectiveness of a potential vaccine and implications for social distancing and face mask use

BackgroundMultiple candidates of COVID-19 vaccines have entered Phase III clinical trials in the United States (US). There is growing optimism that social distancing restrictions and face mask requirements could be eased with widespread vaccine adoption soon.MethodsWe developed a dynamic compartmental model of COVID-19 transmission for the four most severely affected states (New York, Texas, Florida, and California). We evaluated the vaccine effectiveness and coverage required to suppress the COVID-19 epidemic in scenarios when social contact was to return to pre-pandemic levels and face mask use was reduced. Daily and cumulative COVID-19 infection and death cases from 26th January to 15th September 2020 were obtained from the Johns Hopkins University Coronavirus resource center and used for model calibration.ResultsWithout a vaccine (scenario 1), the spread of COVID-19 could be suppressed in these states by maintaining strict social distancing measures and face mask use levels. But relaxing social distancing restrictions to the pre-pandemic level without changing the current face mask use would lead to a new COVID-19 outbreak, resulting in 0.8–4 million infections and 15,000–240,000 deaths across these four states over the next 12 months. Under this circumstance, introducing a vaccine (scenario 2) would partially offset this negative impact even if the vaccine effectiveness and coverage are relatively low. However, if face mask use is reduced by 50% (scenario 3), a vaccine that is only 50% effective (weak vaccine) would require coverage of 55–94% to suppress the epidemic in these states. A vaccine that is 80% effective (moderate vaccine) would only require 32–57% coverage to suppress the epidemic. In contrast, if face mask usage stops completely (scenario 4), a weak vaccine would not suppress the epidemic, and further major outbreaks would occur. A moderate vaccine with coverage of 48–78% or a strong vaccine (100% effective) with coverage of 33–58% would be required to suppress the epidemic. Delaying vaccination rollout for 1–2 months would not substantially alter the epidemic trend if the current non-pharmaceutical interventions are maintained.ConclusionsThe degree to which the US population can relax social distancing restrictions and face mask use will depend greatly on the effectiveness and coverage of a potential COVID-19 vaccine if future epidemics are to be prevented. Only a highly effective vaccine will enable the US population to return to life as it was before the pandemic.     

Massachusetts's experience suggests coverage alone is insufficient to increase addiction disorders treatment

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.     

Women and Health Reform: How National Health Care Can Enhance Coverage,Affordability, and Access for Women (Examples From Massachusetts)

BackgroundMassachusetts women have the highest rates of health insurance coverage in the nation and women's access to care has improved across all demographic groups. However, important challenges persist. As national health reform implementation moves forward under the Affordable Care Act (ACA), states will likely encounter many of the same women's health challenges experienced in Massachusetts over the past 7 years.MethodsA review of the literature and data analyses comparing health care services access, utilization, and cost, and health outcomes from Massachusetts pre- and post-2006 health care reform identified two key challenges in women's continuity of coverage and affordability.ConclusionThese areas are crucial for state and national policymakers to consider in improving women's health as they work to implement health care reform at the state and federal levels.     

Change in Health Insurance Coverage in Massachusetts and Other New England States by Perceived Health Status: Potential Impact of Health Reform

Objectives. We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health.Methods. We used 2003–2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform.Results. The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states—from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs.Conclusions. On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.The sweeping health reform initiative in Massachusetts, An Act Providing Access to Affordable, Quality, Accountable Health Care (enacted April 12, 2006),1 provides a natural experiment with outcomes that may foreshadow those of the comprehensive national health reform President Obama signed into law 4 years later. The Patient Protection and Affordable Care Act (enacted March 23, 2010)2 and amendments in the Health Care and Education Reconciliation Act (enacted March 30, 2010),3 are collectively referred to as the Affordable Care Act (ACA).This landmark federal law includes provisions to strengthen the public health system, provide mandatory funding for prevention and wellness programs and activities, strengthen the Medicare program, implement insurance market reforms, bolster public health and primary care workforce, and improve the overall quality of the nation’s health system. The act focuses on expanding health insurance coverage and improving the health care delivery system beginning with incremental reforms in 2010 and following up with more substantial changes such as individual mandates, employer requirements, expansion of public programs, premium and cost-sharing subsidies to individuals, premium subsidies to employers, tax changes, and health insurance exchanges in 2014. Importantly, the law also prevents insurers from denying health insurance coverage or charging higher premiums on the basis of health status.4,5 The Congressional Budget Office estimates that, when fully implemented in 2019, ACA will provide coverage to an additional 32 million Americans leaving about 23 million nonelderly people uninsured.6Systematic reviews of the literature on the impact of health insurance on health care utilization and health outcomes provide some convincing and some nuanced conclusions. These reviews consistently report evidence of increased utilization of physician and preventive services, improvements in the health of vulnerable populations, and lower mortality, conditional on injury and disease; however, how health insurance affects health outcomes for nonelderly adults remains unclear.7,8From a public health perspective, monitoring implementation of ACA at federal, state, and local levels will be important because this act will change health insurance coverage and access to care, and uptake of care, including preventive services and needed treatment; may alter health care finance and payment structures and care delivery systems as well as health expenditures; and may modify individual and population outcomes of care and health status. Studying the effects of health insurance would ideally rely on experimental evidence7 where health insurance was randomly assigned like the RAND Health Insurance Experiment and the Oregon Medicaid Lottery.9,10 In the absence of randomized experiments, owing to ethical and practical considerations, the need for conducting some social experiments or other approaches to infer causal conclusions from observational data are essential.7,11Fortunately, a natural experiment of near universal health insurance coverage combined with a targeted public health intervention has been unfolding in Massachusetts for more than 3 years and has been the subject of many studies. Researchers have studied various aspects of the impact of Massachusetts health reform, after 1 year,12 over the short term, comparing 18 months before and 18 months after the reform,13 on young adults and children,14,15 and even the effects of the recession.16 This evolving new body of research leaves a gap in our understanding of the impact of health reform by perceived health care need. We examined the impact of the Massachusetts health reform and its public health component on change in health insurance coverage by perceived health. We examined the impact of the natural experiment in Massachusetts as a model to predict likely outcomes of implementing ACA. Because Medicare already covers most of those aged 65 years and older we compared the effectiveness of mandatory versus optional health insurance among only the nonelderly adult population (aged 18–64 years) residing in Massachusetts and other New England states (Connecticut, Maine, New Hampshire, Rhode Island, and Vermont).To do this, we compared data between the 3 years (2003–2005) before and the 3 years (2007–2009) after Massachusetts enacted the health reform law and between Massachusetts and other New England states that had no similar health reform laws. Massachusetts and other New England states had similar sociodemographic population characteristics and macroeconomic profiles (e.g., gross domestic product, unemployment rates) over this time period, including a similar impact of 2 years of recession (2007–2009).17,18 This allows not only “before-versus-after” but also “with-versus-without” analyses, a strategy employed by other researchers to explicate the impact of health reform laws and policy as a control for other elements.16,19We used the Behavioral Risk Factor Surveillance System (BRFSS), the largest and longest-running state-representative, population-based telephone survey that has asked questions about health insurance coverage, health-promoting and health-compromising behaviors, and doctor-diagnosed chronic conditions. Existing federal government and state-sponsored surveys generate different estimates of uninsurance possibly explained by differences in survey design including coverage, reference period, mode, and questionnaire design (wording and placement of questions).20–22 First, we established the quality and the consistency of BRFSS health insurance coverage estimates by comparing these estimates for selected demographic and socioeconomic characteristics with other federal surveys that gather data on health insurance—the American Community Survey (ACS), the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC), and the National Health Interview Survey (NHIS). The US Census Bureau added a question about health insurance to the 2008 ACS leading to the release of the first set of estimates in September 2009.23 The CPS ASEC is the most widely cited source for health insurance statistics. It is annual, timely, relatively large, and has a state-based design. The NHIS is a continuing nationwide survey conducted by the National Center for Health Statistics.23We hypothesized a greater increase in the proportion of nonelderly adults with health insurance coverage in Massachusetts than in other New England states. We further hypothesized that nonelderly adults with greater perceived health care needs would be more likely to obtain health insurance coverage. Groups with greater perceived health care need would show a larger increase in health insurance coverage from prereform to postreform and in Massachusetts compared with other New England states.     

Health care coverage and access for children in an urban state: The New York perspective

Conclusion New York and the nation stand at the brink of an unprecedented opportunity to improve health care coverage and access for children. New York can continue to be a national leader in ensuring access to coverage and care for low-income children by combining eligibility expansions with effective outreach and enrollment efforts. Between half and three-quarters of a million children could benefit if these activities are successful. As monumental an accomplishment as that would be, however, three-quarters of the state's total uninsured population would remain without coverage. Successful advocacy for low-income children should serve as models for additional efforts to provide health care coverage to their parents and to other uninsured adults in the state. During a strong state economy and renewed interest in health care issues, the time is now to seize this momentum and fulfill New York's historic commitment to health care for all its citizens.     

A federalist approach to health reform: the worst way, except for all the others

Support for state action should be part of any strategy to expand health insurance coverage. Decades-long political deadlock in Washington has frustrated national efforts to expand coverage. Some states have already undertaken to do this; others show a determination to do so. Regulatory and legislative flexibility would trigger widespread state action. Whether one thinks that ensuring coverage requires a unified national approach or that diverse conditions require different methods in different states, the likelihood of progress will be advanced if states test out various ways to expand coverage. We describe a practical way by which the federal government can promote state action to expand health insurance coverage.     

Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform

BackgroundMedicaid is a major source of public health care financing for pregnant women and deliveries in the United States. Starting in 2014, some states will extend Medicaid to thousands of previously uninsured, low-income women. Given this changing landscape, it is important to have a baseline of current levels of Medicaid financing for births in each state. This article aims to 1) provide up-to-date, multiyear data for all states, the District of Columbia, and Puerto Rico and 2) summarize issues of data comparability in view of increased interest in program performance and impact assessment.MethodsWe collected 2008–2010 data on Medicaid births from individual state contacts during the winter of 2012–2013, systematically documenting sources and challenges.FindingsIn 2010, Medicaid financed 48% of all births, an increase of 19% in the proportion of all births covered by Medicaid in 2008. Percentages varied among states. Numerous data challenges were found.Conclusions/Implications for Research and PolicyConsistent adoption of the 2003 birth certificate in all states would allow the National Center for Health Statistics Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.     

The Massachusetts approach: a new way to restructure state health insurance markets and public programs

In April 2006, Massachusetts enacted legislation to reorganize both its health insurance markets and a large portion of its health care subsidy system. In this paper we consider how the Massachusetts approach differs from most previous state health reform efforts, while also noting its antecedents. We examine the policy implications of the legislation's key elements and discuss how other states might consider altering the scope and specifics of those components. We conclude that both parts of the Massachusetts reform strategy merit consideration by other states and together hold promise for expanding coverage, particularly by addressing the problem of coverage discontinuity.     

Medicaid coverage for the working uninsured: the role of state policy

Low-income workers face the highest gap in health coverage; 37.3 percent were uninsured in 1999. Although employer-sponsored insurance covered many more low-income workers, state programs are very important to those without private insurance. We examined the wide variations across thirteen representative states in public insurance coverage of low-income workers to develop insights into the reasons for the variations and to suggest strategies for encouraging states to expand public insurance coverage. The analysis suggests that expanded and better-targeted federal assistance coupled with greater state flexibility would be needed to achieve this goal.     

The Oregon Health Plan and public health

The Oregon Health Plan would provide all Oregonians with health insurance through a combination of Medicaid expansion, employer mandates and high-risk coverage, with services delivered largely through managed care. The role of public health in a managed care environment is an important national issue, and one which has received much attention in Oregon. "Cultural" differences between Medicaid and public health have arisen over issues such as whether eligibility assures access, whether the private medical model will provide integrated care, the potential for exploitation of vulnerable populations in a capitated system, and the loss of cost-based Medicaid reimbursement to public clinics. In 1991, legislation required that Oregon's Medicaid managed care plans enter agreements with local health departments to assure their continued participation in providing certain public health services; these agreements are now being implemented. Oregon's experience suggests that any national health system will require a continuum of community and individual health services, with an important role for public health departments.     

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.     

Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults

Objectives. We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.Methods. We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992–2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.Results. The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.Conclusions. Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.Implemented in 1965, Medicaid was designed as publicly funded health insurance coverage for indigent US citizens and legal permanent residents. The program is jointly funded by the state and federal governments, and states are mandated to provide coverage for children younger than 6 years whose family incomes fall below 133%, children between ages 6 and 17 years whose family incomes fall below 100%, and pregnant women whose incomes fall below 133% of the federal poverty level, as defined by the US Department of Health and Human Services1; individuals who are aged, blind, or disabled and who are eligible for Supplemental Security Income; and low-income Medicare beneficiaries. This program has provided health insurance access to a significant number of previously uninsured low-income Americans and continues to be the only route to health care coverage for many people.Nationwide, Medicaid coverage has been found to be associated with several positive outcomes. Medicaid recipients have greater access to medical treatment than uninsured individuals and, therefore, fewer emergency department visits.2–6 Medicaid enrollees have better overall health and lower mortality rates over time than uninsured persons, likely because they have increased access to treatment.7–10 As a result, their medical care is significantly less costly to society, because health problems are more likely to be addressed before the onset of complications and adverse outcomes.11Although the implementation of the Medicaid program has been a largely successful attempt to provide medical insurance, a significant number of low-income adults remain uninsured, mainly because childless adults without qualifying disabilities are ineligible.12–14 In response to this disparity, some states have developed programs to broaden eligibility criteria through a Section 1115 waiver. Massachusetts was among the first states to implement such an initiative, establishing the MassHealth program in July 1997. Among other provisions, the program extended Medicaid eligibility to families and childless adults whose incomes fell below 200% and 133% of the federal poverty level, respectively. MassHealth was jointly funded by the federal and state governments, with Massachusetts paying for roughly 46% of the program.15,16Outcome evaluations of the MassHealth program demonstrated it to be remarkably successful, with significant declines in uninsured rates, particularly among childless adults who would otherwise be ineligible for Medicaid coverage.17,18 Research by Long et al. found that the MassHealth program resulted in a 33% decrease in the rate of uninsured Massachusetts residents.19 Furthermore, Quigley et al. reported that the MassHealth program covers nearly 1 in 6 Massachusetts residents.15 Consequently, it is estimated that only 6% of adults and 3% of children in Massachusetts remained uninsured after implementation of the program.Although evaluations of MassHealth have provided strong support for the program, some evidence suggests that certain marginalized populations are less affected by Medicaid expansion policies than others.16,20 Despite meeting the income eligibility criteria, many people living in poverty remain uninsured because they don''t know they are eligible, they don''t know how to obtain coverage, or they lack any form of identification.21,22 Homeless adults are disproportionately affected by lack of insurance and are reportedly difficult to enroll in public insurance programs.23,24 Although Massachusetts developed several approaches for targeting this hard-to-reach population, evidence suggests that the effort to enroll homeless adults and keep them enrolled faces many logistical barriers.16These challenges are even greater among homeless individuals with substance use disorders. These disorders are common among homeless persons, with prevalence estimates of 40% to 60%.25,26 These individuals generally have significantly greater health care needs, for treatment of, for example, psychiatric disorders, HIV and other sexually transmitted infections, hepatitis, liver disease, lung disease, and wound and skin infections.27–30 The premature mortality rate is significantly higher for homeless individuals than for the general population,27,31 and homeless people with substance use disorders are even more disproportionately affected.31,32 Finally, substance abuse is among the strongest predictors of returning to homelessness among formerly homeless individuals.33–36 Therefore, homeless adults'' lack of the Medicaid coverage necessary to obtain treatment is a significant public health concern.Assessing the impact of MassHealth is especially important in the context of national policy initiatives. Currently, many low-income childless adults qualify for Medicaid benefits because of a physical or mental health disability, but substance abuse is not among the conditions that confer eligibility, so many substance-abusing homeless adults who do not have children are ineligible for Medicaid coverage. However, a major provision of the Affordable Care Act is that all individuals with incomes that fall at or below 133% of the federal poverty level will be eligible for Medicaid effective January 2014, irrespective of parental or disability status. Although a Supreme Court ruling in June 2012 rejected a mandate for states to expand coverage,37 it is still expected that a significant portion of individuals with substance use disorders will benefit tremendously from the law''s expanded eligibility.To date, no large-scale quantitative evaluation has attempted to determine whether marginalized population groups, such as homeless substance-abusing adults, still have difficulty obtaining coverage under the Medicaid expansion.16,20–24 Data from state programs such as MassHealth are useful in assessing whether these groups will benefit from Medicaid expansion to the same extent as other population groups or may be in need of targeted interventions to improve their access. We examined administrative data on admissions to substance abuse treatment programs from 1992 to 2009 to assess the uptake of Medicaid coverage by substance-abusing homeless adults after the implementation of MassHealth in 1997. We assessed whether homeless adults entering substance use disorder treatment programs were less likely than housed adults to be covered by Medicaid. To rule out the potential impact of secular trends in national Medicaid coverage, we compared uptake of Medicaid coverage in adults entering substance abuse programs after 1997 in Massachusetts with rates in other states.     

Intimate Partner Violence and Health Provider Training and Screening in the News

ABSTRACT

Intimate partner violence is a significant women's health issue. Since the news media can play a role in policy development, it is important to understand how newspapers have portrayed training and screening. The purpose of this study was to describe the frequency and nature of print news coverage of health issues related to partner violence, specifically, provider training and screening by health providers. We conducted a content analysis on articles obtained from major city and state capital daily newspapers from 20 states. News articles and editorials mentioning intimate partner violence and provider training and screening were examined for the years 1994 through 2001 (N = 188). Results showed that print news coverage was limited and received low levels of attention, indicating little potential to influence either policy or individual behavior. However, when the issue was covered, little debate or controversy was present, and a broad discussion of the issue was generally provided. News coverage of training and screening could be improved by increasing dissemination of research results, illustrating the policy implications of these issues, and offering resource information to women experiencing violence.     

Mental health parity: what are the gaps in coverage?

BACKGROUND: Mental health benefits in private health insurance plans in the United States are typically less generous than benefits for physical health care services, driving reform efforts to achieve parity in coverage. While there is growing evidence about the effects such legislation would have on the utilization and cost of mental health services, less is known about the impact parity would have on reducing the risk of large out-of-pocket expenses that families would face in the event of mental illness. AIMS OF THE STUDY: We seek to understand the impact that mental health parity would have on the out-of-pocket burden that families would face in the event of mental illness. We focus in particular on variations in coverage across the privately insured population. METHODS: We compare out-of-pocket spending for hypothetical episodes of mental health treatment, first under current insurance coverage in the United States and then under a reform policy of full mental health parity. We exploit detailed informtion on actual health plan benefits using a nationally-representative sample of the privately insured population under age 65 from the 1987 National Medical Expenditure Survey (NMES) that has been carefully aged and reweighted to represent 1995 population and benefit characteristics. RESULTS: Our results show that existing benefits of the U.S. privately insured population under age 65 leave most people at risk of high out-of-pocket costs in the event of a serious mental illness. Moreover, the generosity of existing mental health benefits varies widely across subgroups, particularly across firm size. We find significantly lower out-of-pocket costs when simulating full parity coverage. However, our results show those with less generous mental health coverage tend to have less generous physical health coverage, as well. CONCLUSIONS: Parity would substantially increase generosity of mental health coverage for most of the privately insured population. The wide variation in the generosity of existing mental health benefits suggests that there are likely to be differential impacts from a parity mandate. Those with limited physical health coverage would still be at significant financial risk for catastrophic mental illness.     

A review of national health surveys in India

Several rounds of national health surveys have generated a vast amount of data in India since 1992. We describe and compare the key health information gathered, assess the availability of health data in the public domain, and review publications resulting from the National Family Health Survey (NFHS), the District Level Household Survey (DLHS) and the Annual Health Survey (AHS). We highlight issues that need attention to improve the usefulness of the surveys in monitoring changing trends in India’s disease burden: (i) inadequate coverage of noncommunicable diseases, injuries and some major communicable diseases; (ii) modest comparability between surveys on the key themes of child and maternal mortality and immunization to understand trends over time; (iii) short time intervals between the most recent survey rounds; and (iv) delays in making individual-level data available for analysis in the public domain. We identified 337 publications using NFHS data, in contrast only 48 and three publications were using data from the DLHS and AHS respectively. As national surveys are resource-intensive, it would be prudent to maximize their benefits. We suggest that India plan for a single major national health survey at five-year intervals in consultation with key stakeholders. This could cover additional major causes of the disease burden and their risk factors, as well as causes of death and adult mortality rate estimation. If done in a standardized manner, such a survey would provide useable and timely data to inform health interventions and facilitate assessment of their impact on population health.