Uninsurance,Underinsurance, and Health Care Utilization in Mexico by US Border Residents

Using data from the 2008 Cross-Border Utilization of Health Care Survey, we examined the relationship between United States (US) health insurance coverage plans and the use of health care services in Mexico by US residents of the US-Mexico border region. We found immigrants were far more likely to be uninsured than their native-born counterparts (63 vs. 27.8 %). Adults without health insurance coverage were more likely to purchase medications or visit physicians in Mexico compared to insured adults. However, adults with Medicaid coverage were more likely to visit dentists in Mexico compared to uninsured adults. Improving health care access for US residents in the southwestern border region of the country will require initiatives that target not only providing coverage to the large uninsured population but also improving access to health care services for the large underinsured population.     

The link between past informal payments and willingness of the Hungarian population to pay formal fees for health care services: results from a contingent valuation study

We examine the willingness of health care consumers to pay formal fees for health care use and how this willingness to pay is associated with past informal payments. We use data from a survey carried out in Hungary in 2010 among a representative sample of 1,037 respondents. The contingent valuation method is used to elicit the willingness to pay official charges for health care services covered by the social health insurance if certain quality attributes (regarding the health care facility, access to the services and health care personnel) are guaranteed. A bivariate probit model is applied to examine the relationship between willingness to pay and past informal payments. We find that 66 % of the respondents are willing to pay formal fees for specialist examinations and 56 % are willing to pay for planned hospitalizations if these services are provided with certain quality and access attributes. The act of making past informal payments for health care services is positively associated with the willingness to pay formal charges. The probability that a respondent is willing to pay official charges for health care services is 22 % points higher for specialist examinations and 45 % points higher for hospitalization if the respondent paid informally during the last 12 months. The introduction of formal fees should be accompanied by adequate service provision to assure acceptance of the fees. Furthermore, our results suggest that the problem of informal patient payments may remain even after the implementation of user fees.     

On the game: women and sex work

Latinos living with HIV residing in the US-Mexico border region frequently seek care on both sides of the border. Given this fact, a border health perspective to understanding barriers to care is imperative to improve patient health outcomes. This qualitative study describes and compares experiences and perceptions of Mexican and US HIV care providers regarding barriers to HIV care access for Latino patients living in the US-Mexico border region. In 2010, we conducted in-depth qualitative interviews with HIV care providers in Tijuana (n = 10) and San Diego (n = 9). We identified important similarities and differences between Mexican and US healthcare provider perspectives on HIV care access and barriers to service utilisation. Similarities included the fact that HIV-positive Latino patients struggle with access to ART medication, mental health illness, substance abuse and HIV-related stigma. Differences included Mexican provider perceptions of medication shortages and US providers feeling that insurance gaps influenced medication access. Differences and similarities have important implications for cross-border efforts to coordinate health services for patients who seek care in both countries.     

Identifying health insurance predictors and the main reported reasons for being uninsured among US immigrants by legal authorization status

This study identifies differences in health insurance predictors and investigates the main reported reasons for lacking health insurance coverage between short‐stayed (≤10 years) and long‐stayed (>10 years) US immigrant adults to parse the possible consequences of the Affordable Care Act among immigrants by length of stay and documentation status. Foreign‐born adults (18‐64 years of age) from the 2009 California Health Interview Survey are the study population. Health insurance coverage predictors and the main reasons for being uninsured are compared across cohorts and by documentation status. A logistic‐regression two‐part multivariate model is used to adjust for confounding factors. The analyses determine that legal status is a strong health insurance predictor, particularly among long‐stayed undocumented immigrants. Immigration status is the main reported reason for lacking health insurance. Although long‐stayed documented immigrants are likely to benefit from the Affordable Care Act implementation, undocumented immigrants and short‐stayed documented immigrants may encounter difficulties getting health insurance coverage. Copyright © 2013 John Wiley & Sons, Ltd.     

Willingness to pay for social health insurance among informal sector workers in Wuhan, China: a contingent valuation study

Background

Most of the about 140 million informal sector workers in urban China do not have health insurance. A 1998 central government policy leaves it to the discretion of municipal governments to offer informal sector workers in cities voluntary participation in a social health insurance for formal sector workers, the so-called 'basic health insurance'(BHI)

Methods

We used the contingent valuation method to assess the maximum willingness to pay (WTP) for BHI among informal sector workers, including unregistered rural-to-urban migrants, in Wuhan City, China. We selected respondents in a two-stage self-weighted cluster sampling scheme

Results

On average, informal sector workers were willing to pay substantial amounts for BHI (30 Renminbi (RMB), 95% confidence interval (CI) 27-33) as well as substantial proportions of their incomes (4.6%, 95% CI 4.1-5.1%). Average WTP increased significantly when any one of the copayments of the BHI was removed in the valuation: to 51 RMB (95% CI 46-56) without reimbursement ceiling; to 43 RMB (95% CI 37-49) without deductible; and to 47 RMB (95% CI 40-54) without coinsurance. WTP was higher than estimates of the cost of BHI based on past health expenditure or on premium contributions of formal sector workers. Predicted coverage with BHI declined steeply with the premium contribution at low contribution levels When we applied equity weighting in the aggregation of individual WTP values in order to adjust for inequity in the distribution of income, mean WTP for BHI increased with inequality aversion over a plausible range of the aversion parameter. Holding other factors constant in multiple regression analysis, for a 1% increase in income WTP for BHI with different copayments increased by 0.434-0.499% (all p < 0.0001), and for a 1% increase in past health care expenditure WTP increased by 0.076-0.148% (all p < 0.0004). Being male, a migrant, or without permanent employment significantly decreased WTP for BHI. Education was not a significant determinant of WTP for BHI

Conclusion

Our results suggest that Chinese municipal governments should allow informal sector workers to participate in the BHI. From a normative perspective, BHI for informal sector workers is likely to increase social welfare because average WTP for BHI is significantly higher than estimates of the average cost of BHI. We further find that informal sector workers do not value the BHI as a mechanism to recover the relatively frequent but small financial losses associated with common illnesses, but because it protects against the rare but large financial losses associated with catastrophic care. From a behavioural perspective, our results predict that at a price equal to the average premium contribution of formal sector workers 35% of informal sector workers will enrol in the BHI. Subsidies and changes in insurance attributes (e.g. including catastrophic care and portability) should be effective in increasing BHI coverage. In addition, coverage should expand with rising incomes among informal sector workers in China. Finally, adverse selection will be unlikely to be a large problem, if the BHI is offered to informal sector workers.     

Explaining public support (or lack thereof) for extending health coverage to undocumented immigrants

While the recent passage of health care reform is estimated to provide millions of currently uninsured Americans with access to health coverage, undocumented immigrants are excluded from federal mandates. Since federal reform excludes undocumented immigrants, state governments will largely decide the fate of this vulnerable population. This article investigates public support for including undocumented immigrants in state health care reform efforts in New Mexico. Understanding the public's perception of extending health coverage to this population is important because public opinion influences health policy formation at the state and federal levels. Our results suggest that there is little support for including undocumented immigrants (or recent migrants from other parts of the United States) in state health care reform, particularly when compared with other segments of the New Mexican population, such as the homeless or unemployed. Our discussion highlights the economic and public health consequences of excluding undocumented immigrants from coverage options.     

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.     

Immigrants and the Affordable Care Act: Changes in Coverage and Access to Care by Documentation Status

Little is known about the effects of the ACA’s coverage expansion among immigrant groups of differing immigration status. Using data from the California Health Interview Survey (2003–2016), we compare changes in health coverage and access to care among immigrants in California before and after implementation of the ACA. We find that the ACA has led to major gains in coverage for lawful permanent residents in California, similar in scope to changes among citizens. However, unauthorized immigrants have experienced only modest increases in coverage, with the result disparity in uninsured rates for this group relative to citizens and permanent residents widening considerably since 2014. Findings indicate a significant increase in having a usual source of care across all groups, but without a significant change in disparities for this outcome. Our results have important implications for the intersection of health policy, immigration, and health equity.

     

Latino adults' health insurance coverage: an examination of Mexican and Puerto Rican subgroup differences

Lack of health insurance is a serious problem in the United States. Using data from the 1996 Medical Expenditure Panel Survey, this paper examines how insurance varies between black, white, and Latino adults. Because Latino subgroups are not homogeneous, the paper also compares the factors associated with health insurance status for Mexican and Puerto Rican adults. Results indicate that access to private health insurance for Latino adults was more closely associated with workplace characteristics than employment itself. Time lived in the United States was a major factor associated with being uninsured for Mexican adults, while language barriers were a major factor limiting Puerto Rican individuals' access to private health insurance. The paper suggests two approaches for decreasing uninsurance among Latino adults: (1) strengthening the link between employment and private health insurance and (2) addressing disparities in access to public coverage for racial and ethnic groups, including recent immigrants.     

Why Uninsured Free Clinic Patients Don’t Apply for Affordable Care Act Health Insurance in a Non-expanding Medicaid State

Even after the introduction of the Patient Protection and Affordable Care Act (ACA), uninsured visits remain high, especially in states that opted out of Medicaid expansion. Since the ACA does not provide universal coverage, free clinics serve as safety nets for the un- or under-insured, and will likely continue serving underserved populations. The purpose of this study is to examine factors influencing intentions to not apply for health insurance via the ACA among uninsured free clinic patients in a state not expanding Medicaid. Uninsured primary care patients utilizing a free clinic (N = 551) completed a self-administered survey in May and June 2015. Difficulty obtaining information, lack of instruction to apply, and cost, are major factors influencing intention not to apply for health insurance through the ACA. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of perceived barriers to applying for health insurance through the ACA. Age is an important factor impacting individuals’ intentions not to apply for health insurance through the ACA, as older patients in particular need assistance to obtain relevant information about the ACA and other resources. A number of unchangeable factors limit the free clinics’ ability to promote enrollment of health insurance through the ACA. Yet free clinics could be able to provide some educational programs or the information of resources to patients. In particular, non-US born English speakers, Spanish speakers, and older adults need specific assistance to better understand health insurance options available to them.     

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.     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

Access to care and health insurance coverage for workers with disabilities: Outcomes by state-level responses to the ACA

BackgroundStates had flexibility in their implementation of the Patient Protection and Affordable Care Act (ACA) Medicaid expansions, which may have led to variation in coverage and changes in access to care for workers with disabilities.Objective/hypothesisTo examine differential trends in health insurance coverage and access to care among workers with disabilities by states’ decisions about expanding Medicaid under the ACA.MethodsWe aggregated data from the National Health Interview Survey into groups by time period relative to ACA implementation: pre-ACA (2006–2009), early ACA (2010–2013), and later ACA (2014–2017). We produced health insurance and access statistics for each time period, by state-level Medicaid expansion status.ResultsUninsurance rates decreased after 2014 in all states, regardless of the state’s decision whether to expand Medicaid. There was a substantial increase after 2014 in the share of workers with disabilities covered by Medicaid in states that expanded in that year; in other states, workers with disabilities experienced larger increases in privately purchased coverage. At the same time, the share of workers with disabilities reporting cost-related barriers to care declined markedly in 2014 Medicaid expansion states, but it increased slightly in the non-expansion states. Structural barriers to accessing care increased in all states, with the smallest increase in 2014 expansion states.ConclusionsMedicaid coverage and cost-related access to care improved significantly among workers with disabilities in 2014 Medicaid expansion states, both overall and relative to workers with disabilities in non-expansion states.     

Cervical Cancer Screening in the US–Mexico Border Region: A Binational Analysis

Cervical cancer mortality is high along the US–Mexico border. We describe the prevalence of a recent Papanicolaou screening test (Pap) among US and Mexican border women. We analyzed 2006 cross-sectional data from Mexico’s National Survey of Health and Nutrition and the US Behavioral Risk Factor Surveillance System. Women aged 20–77 years in 44 US border counties (n = 1,724) and 80 Mexican border municipios (n = 1,454) were studied. We computed weighted proportions for a Pap within the past year by age, education, employment, marital status, health insurance, health status, risk behaviors, and ethnicity and adjusted prevalence ratios (APR) for the US, Mexico, and the region overall. Sixty-five percent (95 %CI 60.3–68.6) of US women and 32 % (95 %CI 28.7–35.2) of Mexican women had a recent Pap. US residence (APR = 2.01, 95 %CI 1.74–2.33), marriage (APR = 1.31, 95 %CI 1.17–1.47) and insurance (APR = 1.38, 95 %CI 1.22–1.56) were positively associated with a Pap test. Among US women, insurance and marriage were associated (APR = 1.21, 95 %CI 1.05–1.38 and 1.33, 95 %CI 1.10–1.61, respectively), and women aged 20–34 years were about 25 % more likely to have received a test than older women. Insurance and marriage were also positively associated with Pap testing among Mexican women (APR = 1.39, 95 %CI 1.17–1.64 and 1.50; 95 %CI 1.23–1.82, respectively), as were lower levels of education (≤8th grade or 9th–12th grade versus some college) (APR = 1.74; 95 %CI 1.21–2.52 and 1.60; 95 %CI 1.03–2.49, respectively). Marriage and insurance were associated with a recent Pap test on both sides of the border. Binational insurance coverage increases and/or cost reductions might bolster testing among unmarried and uninsured women, leading to earlier cervical cancer diagnosis and potentially lower mortality.     

Health Insurance Coverage and Medical Expenditures of Immigrants and Native-Born Citizens in the United States

Objectives. I examined insurance coverage and medical expenditures of both immigrant and US-born adults to determine the extent to which immigrants contribute to US medical expenditures.Methods. I used data from the 2003 Medical Expenditure Panel Survey to perform 2-part multivariate analyses of medical expenditures, controlling for health status, insurance coverage, race/ethnicity, and other sociodemographic factors.Results. Approximately 44% of recent immigrants and 63% of established immigrants were fully insured over the 12-month period analyzed. Immigrants'' per-person unadjusted medical expenditures were approximately one half to two thirds as high as expenditures for the US born, even when immigrants were fully insured. Recent immigrants were responsible for only about 1% of public medical expenditures even though they constituted 5% of the population. After controlling for other factors, I found that immigrants'' medical costs averaged about 14% to 20% less than those who were US born.Conclusions. Insured immigrants had much lower medical expenses than insured US-born citizens, even after the effects of insurance coverage were controlled. This suggests that immigrants'' insurance premiums may be cross-subsidizing care for the US-born. If so, health care resources could be redirected back to immigrants to improve their care.There is substantial public policy disagreement in the United States about whether the nation should restrict or expand health care for immigrants. Polls show that roughly half of Americans believe that immigrants are a burden on the nation because they take jobs, housing, and health care from US-born citizens.¹ Some further believe that “high rates of immigration are straining the health care system to the breaking point”² or that “illegal aliens in this country are taking a large part of our health care dollars.”³ But others believe that steps should be taken to bolster immigrants'' health care, such as restoring their eligibility for Medicaid or having insurers pay for interpreter services for patients who are not proficient in English.^4–6Researchers have found that immigrants'' unadjusted per capita medical utilization and expenditures are actually much lower than those of US-born citizens. Mohanty et al. analyzed the 1998 Medical Expenditure Panel Survey (MEPS) and found that immigrants'' average per capita medical costs were approximately half those of US-born citizens.⁷ Goldman et al. examined data from a 2000 Los Angeles survey and concluded that immigrants incurred a disproportionately small share of medical expenses, both government-paid expenses and overall expenses.⁸ These findings are consonant with studies showing that immigrants have less access to health insurance and use less health care than the native born.^9–14 However, previous research has not clearly examined the relationships among immigrants'' health care expenditures, immigration status, and insurance coverage. To learn more about these relationships, I analyzed data from a recent nationally representative survey of adult US residents.     

Expanding the Universe of Universal Coverage: The Population Health Argument for Increasing Coverage for Immigrants

As the US recession deepens, furthering the debate about healthcare reform is now even more important than ever. Few plans aimed at facilitating universal coverage make any mention of increasing access for uninsured non-citizens living in the US, many of whom are legally restricted from certain types of coverage. We conducted a critical review of the public health literature concerning the health status and access to health services among immigrant populations in the US. Using examples from infectious and chronic disease epidemiology, we argue that access to health services is at the intersection of the health of uninsured immigrants and the general population and that extending access to healthcare to all residents of the US, including undocumented immigrants, is beneficial from a population health perspective. Furthermore, from a health economics perspective, increasing access to care for immigrant populations may actually reduce net costs by increasing primary prevention and reducing the emphasis on emergency care for preventable conditions. It is unlikely that proposals for universal coverage will accomplish their objectives of improving population health and reducing social disparities in health if they do not address the substantial proportion of uninsured non-citizens living in the US.