The Health Effects of Medicare for the Near-Elderly Uninsured

Objective. To determine whether Medicare enrollment at age 65 has an effect on the health trajectory of the near-elderly uninsured.
Data Sources. Eight biennial waves (1992–2006) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51–61 year olds and their spouses.
Study Design. We use a quasi-experimental approach to compare the health effects of insurance for the near-elderly uninsured with previously insured contemporaneous controls. The primary outcome measure is overall self-reported health status combined with mortality (i.e., excellent to very good, good, fair to poor, dead).
Results. The change in the trajectory of overall health status for the previously uninsured that can be attributed to Medicare is small and not statistically significant. For every 100 persons in the previously uninsured group, joining Medicare is associated with 0.6 fewer in excellent or very good health (95 percent CI: −4.8, 3.3), 0.3 more in good health (95 percent CI: −3.8, 4.1), 2.5 fewer in fair or poor health (95 percent CI: −7.4, 2.3), and 2.8 more dead (−4.0, 10.0) by age 73. The health trajectory patterns from physician objective health measures are similarly small and not statistically significant.
Conclusions. Medicare coverage at age 65 for the previously uninsured is not linked to improvements in overall health status.     

Children’s Receipt of Health Care Services and Family Health Insurance Patterns

PURPOSE Insured children in the United States have better access to health care services; less is known about how parental coverage affects children’s access to care. We examined the association between parent-child health insurance coverage patterns and children’s access to health care and preventive counseling services.METHODS We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002–2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children’s unmet health care and preventive counseling needs.RESULTS Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02–2.97), no usual source of care (OR = 1.31; 95% CI, 1.10–1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01–1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04–1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.CONCLUSIONS Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.     

Exploring Racial,Gender, and Insurance Disparities in Patients with Osteoporotic Fractures

The objective of this study is to examine racial, gender, and insurance disparities in hospital outcomes among patients diagnosed with osteoporotic fractures aged 55 years and older. A total of 36,153 patients were included in this study. The sample was constructed from de-identified patient-level data for 2011 through 2014 from the Virginia Health Information (VHI) inpatient discharge database. Differences in mortality and 30-day readmission across race, gender, and insurance status were examined using logistic regression and generalized linear models for hospital charges and length of stay. Whites and Asians had a shorter stay than Blacks [5.2 days (95% confidence interval (CI) 5.1–5.3) and 5.0 days (95% CI 4.7–5.2) vs. 5.6 days (95% CI 5.4–5.7)], while Hispanics had a significantly longer stay [6.0 days (95% CI 5.6–6.5)]. On average, total charges were the highest among Blacks [$37,916 (95% CI 36,784–39,083)]. All outcomes were poorer for men than women. Privately and publicly insured patients were more likely to be readmitted [odds ratio (OR) 1.6 (95% CI 1.0-2.6) and OR 2.0 (95% CI 1.3–3.2)] and had a shorter stay than the uninsured [4.9 days (95% CI 4.8–5.0) and 5.2 days (95% CI 5.1–5.3) vs. 5.7 days (95% CI 5.4–6.0)], while privately insured patients had considerably lower total charges than those who were uninsured [$34,163 (95% CI 33,214–35,139) vs. $36,335 (95% CI 34,334–38,452)]. As evidenced from this study, there are racial, gender, and insurance disparities in health outcomes. These results and further exploration of these disparities could provide information necessary for strategies to improve these outcomes in at-risk patients diagnosed with osteoporotic fractures.     

Variations in healthcare measures by insurance status for patients receiving ventilator support

OBJECTIVE: To examine differences in healthcare delivery by expected health insurance status for hospitalized patients in diagnosis-related group (DRG) 475, respiratory system diagnoses requiring intubation and continuous ventilator support. DESIGN: A survey, derived from the Healthcare Cost and Utilization Project interstate database, of the care delivered to 21,149 adult patients in DRG 475 and hospitalized in one of 718 acute-care hospitals in nine states. Multivariate analysis was performed, controlling for demographic and hospital factors. RESULTS: Patients insured by health maintenance organizations (HMOs) had significantly lower rates of inpatient mortality (odds ratio [OR], 0.84; 95% confidence interval [CI95], 0.73-0.96), 14.3 more procedures performed (CI95, 11.5-17.2), 7.0% shorter hospitalizations (CI95, 12.5-1.6), and 5.2% higher charges (CI95, 0.4-10.0) than those with traditional private insurance. In addition, patients insured by Medicaid had 3.5% more procedures performed (CI95, 1.6-5.4), 10.4% longer lengths of hospitalization (CI95, 6.7-14.0), and 13.8% higher charges (CI95, 10.6-17.0) than those with traditional private insurance. Finally, the uninsured had significantly lower rates of inpatient mortality (OR, 0.87; CI95, 0.77-0.99), 8.5% more procedures performed (CI95, 6.0-11.1), 16.5% shorter hospitalizations (CI95, 21.5-11.6), and 13.4% lower charges (CI95, 17.8-9.0) than those with traditional private insurance. CONCLUSION: Variations in healthcare measures by insurance status for this DRG emphasize the importance of more careful analyses of insurance categories as a determinant of healthcare access and outcomes. Expected insurance status was an independent predictor of cost. Private insurance and HMO populations differed significantly in outcome and cannot be considered equivalent.     

Uninsured vs. insured population: variations among nonelderly Americans

This study identified the underlying demographic and socioeconomic factors associated with insurance status among nonelderly Americans (age 19-64), as well as compared health care utilization between insured and uninsured. Data from the Community Tracking Study 1996-1997 Household Survey were analyzed. Approximately 74 percent of uninsured Americans are nonelderly Americans. Among the nonelderly Americans, about 17 percent are uninsured. Our findings show that insurance status varies significantly by region, age, race, gender, marital status, income, education, employment status, and health status. Also, the insured nonelderly Americans were found to have better access to health care than the uninsured nonelderly.     

Health Insurance and Mortality in US Adults

Objectives. A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data.Methods. We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death.Results. Among all participants, 3.1% (95% confidence interval [CI] = 2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI = 1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio = 1.40; 95% CI = 1.06, 1.84) than those with insurance.Conclusions. Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.The United States stands alone among industrialized nations in not providing health coverage to all of its citizens. Currently, 46 million Americans lack health coverage.¹ Despite repeated attempts to expand health insurance, uninsurance remains commonplace among US adults.Health insurance facilitates access to health care services and helps protect against the high costs of catastrophic illness. Relative to the uninsured, insured Americans are more likely to obtain recommended screening and care for chronic conditions² and are less likely to suffer undiagnosed chronic conditions³ or to receive substandard medical care.⁴Numerous investigators have found an association between uninsurance and death.^5–14 The Institute of Medicine (IOM) estimated that 18 314 Americans aged between 25 and 64 years die annually because of lack of health insurance, comparable to deaths because of diabetes, stroke, or homicide in 2001 among persons aged 25 to 64 years.⁴ The IOM estimate was largely based on a single study by Franks et al.⁵ However, these data are now more than 20 years old; both medical therapeutics and the demography of the uninsured have changed in the interim.We analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III). NHANES III collected data on a representative sample of Americans, with vital status follow-up through 2000. Our objective was to evaluate the relationship between uninsurance and death.     

THE EFFECT OF NATIONAL HEALTH INSURANCE ON MORTALITY AND THE SES–HEALTH GRADIENT: EVIDENCE FROM THE ELDERLY IN TAIWAN

Using the difference‐in‐difference‐in‐differences method, we examine the effect of the National Health Insurance (NHI) on mortality, self‐assessed health, and functional limitations of the elderly and seek to determine whether the effect is spread equally across health classes. We find that the NHI only has an effect on the death hazard, and it is the least healthy who benefit the most. The death hazard falls by 16–48% and 3–9% for the least health and the healthiest, respectively. The decline in the hazard ratio for the least healthy among the uninsured is 58% greater than that of their counterparts among the insured. Moreover, female participants benefit more from the NHI than male participants. We find no significant effect of the NHI in the SES–health gradient except for the education–death hazard gradient. The gap in the education‐death hazard gradient between the insured and previously uninsured is significantly reduced by 7–31% after 1995. The hazard ratio among the less‐educated in the treatment group also falls by 55% relative to that in the comparison group. The NHI appears to have prolonged lives but has failed to improve the functional limitations, which might have contributed to the rapid increase in the demand for long‐term caregivers in recent years. Copyright © 2012 John Wiley & Sons, Ltd.     

The State Children's Health Insurance Program: a multicenter trial of outreach through the emergency department

OBJECTIVES: We evaluated emergency department (ED)-based outreach for the State Children's Health Insurance Program (SCHIP). METHODS: We conducted a multicenter trial among uninsured children (< or = 18 years) who presented to 5 EDs in 2001 and 2002. On-site staff enrolled consecutive subjects for a control period followed by an intervention period during which staff handed out SCHIP applications to the uninsured. The primary outcome was state-level confirmation of insured status at 90 days. RESULTS: We followed 223 subjects (108 control, 115 intervention) by both phone interview and state records. Compared to control subjects, those receiving a SCHIP application were more likely to have state health insurance at 90 days (42% vs 28%; P<.05; odds ratio [OR]=3.8; 95% confidence interval [CI]=1.7, 8.6). Although the intervention effect was prominent among 118 African Americans (50% insured after intervention vs 31% of controls, P<.05), lack of family enrollment in other public assistance programs was the primary predictor of intervention success (OR=3.7; 95% CI=1.6, 8.4). CONCLUSIONS: Handing out insurance applications in the ED can be an effective SCHIP enrollment strategy, particularly among minority children without connections to the social welfare system. Adopted nationwide, this simple strategy could initiate insurance coverage for more than a quarter million additional children each year.     

Prenatal care use and health insurance status.

Many observers explain the prevalence of inadequate prenatal care in the United States by citing demographic or psychosocial factors. But few have evaluated the barriers faced by women with different health insurance status and socioeconomic backgrounds. In this study of 149 women at six hospitals in Minneapolis, insurance status was significantly related to the source of prenatal care (p less than .0001). Private physicians cared for 52 percent of privately insured, 23 percent of Medicaid-insured, and two percent of uninsured women. Public clinics were the primary source of care for Medicaid and uninsured women, who, compared to privately insured women, experienced longer waiting times (p less than .001) during prenatal visits and were more likely (p less than .01) to lack continuity of care with a provider. Multiple measures, including expanding Medicaid eligibility, may help correct these problems.     

Effects of health insurance and race on colorectal cancer treatments and outcomes

OBJECTIVES: We hypothesized that health insurance payer and race might influence the care and outcomes of patients with colorectal cancer. METHODS: We examined treatments received for all incident cases of colorectal cancer occurring in Florida in 1994 (n = 9551), using state tumor registry data. We also estimated the adjusted risk of death (through 1997), using proportional hazards regression analysis controlling for other predictors of mortality. RESULTS: Treatments received by patients varied considerably according to their insurance payer. Among non-Medicare patients, those in the following groups had higher adjusted risks of death relative to commercial fee-for-service insurance: commercial HMO (risk ratio [RR] = 1.40; 95% confidence interval [CI] = 1.18, 1.67; P = .0001), Medicaid (RR = 1.44; 95% CI = 1.06, 1.97; P = .02), and uninsured (RR = 1.41; 95% CI = 1.12, 1.77; P = .003). Non-Hispanic African Americans had higher mortality rates (RR = 1.18; 95% CI = 1.01, 1.37; P = .04) than non-Hispanic Whites. CONCLUSIONS: Patients with colorectal cancer who were uninsured or insured by Medicaid or commercial HMOs had higher mortality rates than patients with commercial fee-for-service insurance. Mortality was also higher among non-Hispanic African American patients.     

Lengthening Spells of Uninsurance and Their Consequences

The lengths of time adults are without health insurance have increased since 1988, as shown by data from 1,235 household interviews completed during 1992 in Nebraska. Rural residents without insurance have experienced longer such spells than their urban counterparts. Thus, while rates of uninsurance are nearly the same between urban and rural residents, important differences exist. The relationship between insurance status and physician utilization is consistent during the five years (1989 to 1993) covered in this study. Continuously insured persons have the most physician visits, followed by those intermittently insured, followed by those continuously uninsured. The number of physician visits was expected to increase when respondents moved from uninsured to insured status. However, among urban respondents, the number of visits declined; among residents in rural frontier counties (fewer than six person per square mile) and for respondents in rural nonfrontier counties, there was no significant difference. This study points out some differences between rural and urban populations regarding insurance status, even when the overall rates of uninsurance are equal.     

Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status.

OBJECTIVES. This study was designed to determine whether resource use and mortality differed by insurance status for patients with acute trauma. METHODS. All adults emergently hospitalized in Massachusetts during 1990 with acute trauma (n = 15,008) were examined. RESULTS. After adjustment for confounders, uninsured patients were as likely to receive care in an intensive care unit as were patients with private insurance (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.85, 1.11) but were less likely to undergo an operative procedure (OR = 0.68, 95% CI = 0.63, 0.74) or physical therapy (OR = 0.61, 95% CI = 0.57,0.67) and were more likely to die in a hospital (OR = 2.15, 95% CI = 1.44, 3.19). Compared with patients with private insurance, those with Medicaid were less likely to receive an operative procedure (0.85, 0.75-0.97), were equally likely to receive care in an intensive care unit (OR = 1.05, 95% CI = 0.86, 1.30) or physical therapy (OR = 0.90, 95% CI = 0.79, 1.02), and were no more likely to die (OR = 1.28, 95% CI = 0.69,2.39). CONCLUSIONS. These results suggest that the uninsured receive less trauma-related care and have a higher mortality rate. The excess mortality in uninsured patients may be avoided if their resource use is increased to that of insured patients.     

A description of outpatient drug use in rural China: evidence of differences due to insurance coverage

This paper describes the effects of health financing systems (insurance) on outpatient drug use in rural China. 1320 outpatients were interviewed (exit interview) in the randomly selected county, township and village health care facilities in five counties in three provinces of central China. The interview was face to face. Questions were asked by a trained interviewer and were answered by patient him/herself. The main finding was that health insurance appeared to influence drug use in outpatient services. The average number of drugs per visit was 2·56 and drug expenditures per visit was 16·9 yuan. Between insured and uninsured (out‐of‐pocket) groups, there were significant differences in the number of drugs and drug expenditures per visit. The insured had a lower number of drugs and a higher drug expenditure per visit than the uninsured, implying the use of more expensive drugs per visit than the uninsured. There were also significant differences in the number of drugs and drug expenditures per visit between the types of insurance. One third of the drugs were anti‐infectives, most of which were penicillin, gentamycin and sulfonamides. The results imply that uninsured patients do not receive the same care as the insured do even if they have the same needs. The fee‐for‐service financing for hospitals and health insurance have changed health providers' and consumers' behaviour and resulted in the increase of medical expenditure. Copyright © 1999 John Wiley & Sons, Ltd.     

Utilization of Health Care Services Among Adults Attending a Health Fair in South Los Angeles County

A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 ± 2.2) than those who did (8.0 ± 2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care.     

Financing health care for adolescents: Problems,prospects, and proposals

Currently, one in every seven adolescents, aged 10–18, is uninsured. This translates to nearly 5 million uninsured adolescents nationwide. Uninsured adolescents, as opposed to insured adolescents, are more likely to be members of poor and minority families. In addition, adolescents without health insurance use fewer health services than their insured counterparts even after controlling for health status differences. Improving the health insurance status of adolescents is becoming an important public policy objective, although Congress recently rejected legislation that would have expanded Medicaid coverage for poor adolescents. Despite this setback, legislators and child health associates are increasingly striving for public and private insurance expansions for adolescents. These efforts are described, and the prospects for future improvements in health insurance coverage of adolescents are discussed.     

Does Major Illness Cause Financial Catastrophe?

Objective. We examine the financial impact of major illnesses on the near‐elderly and how this impact is affected by health insurance. Data Sources. We use RAND Corporation extracts from the Health and Retirement Study from 1992 to 2006. 1 Study Design. Our dependent variable is the change in household assets, excluding the value of the primary home. We use triple difference median regressions on a sample of newly ill/uninsured near elderly (under age 65) matched to newly ill/insured near elderly. We also include a matched control group of households whose members are not ill. Results. Controlling for the effects of insurance status and illness, we find that the median household with a newly ill, uninsured individual suffers a statistically significant decline in household assets of between 30 and 50 percent relative to households with matched insured individuals. Newly ill, insured individuals do not experience a decline in wealth. Conclusions. Newly ill/uninsured households appear to be one illness away from financial catastrophe. Newly ill insured households who are matched to uninsured households appear to be protected against financial loss, at least in the near term.     

The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.