Insurance status and access to health services among poor persons.

OBJECTIVE: We examine the relationship between health insurance status and access to care among low-income persons 65 years of age and under, taking into account their social demographic characteristics and health care needs. DATA SOURCES AND STUDY SETTING. Study groups consist of the subsamples of persons with incomes between 100 and 150 percent of the federal poverty level and those below the federal poverty level interviewed in the 1983, 1984, and 1986 Health Interview Surveys (HIS) of the National Center for Health Statistics. Sample sizes range from about 6,000 to 11,000 depending on the proportion of each study group administered the insurance supplement. STUDY DESIGN. Annual visits and whether hospitalized during a year are used as measures of access to medical care. The analysis consists of identifying predictors of use of services (i.e., health status and social characteristics) and, taking them into account, examining the relationship of insurance status to access to care. This was first undertaken on the 1983 survey; the models obtained then are replicated on the other two years of data. DATA COLLECTION/EXTRACTION METHODS. The HIS utilizes in-person interviews to gather health and medical history information from a stratified random sample of the U.S. population. Data were obtained through public use tapes distributed by the National Center for Health Statistics. PRINCIPAL FINDINGS. Results are consistent for all three years among persons in poverty. Being covered by Medicaid, in contrast to having private insurance or being without health insurance, is related to use of both ambulatory care and hospital care. The access differences for persons in poverty, regardless of their vulnerability or "risk" of requiring medical care, are marked and generally statistically significant. Among the near-poor the same findings occur, although the differences are less sharp and less often statistically significant. CONCLUSIONS. The most obvious explanation is that the poor, and to a considerable extent the near-poor, have limited access because of copayments and deductibles that are typically part of private insurance coverage. The findings raise policy questions regarding the utility of either "play or pay" employer-provided insurance or income tax deductions to increase access.     

Medical savings accounts: a core feature of Singapore's health care system

In 1984 Singapore adopted a system of Medisave accounts, individually owned accounts used to pay for many of the health care expenditures that in Germany would normally be covered by the obligatory or private health insurance. The fact that people are spending their own money rather than that of a third-party insurer has helped to curtail Singapore's health care costs, which were about 2.6% of gross domestic product in 1999 (Germany: 10.5%). Even with these low expenditures, the income of Singapore physicians is about the same in relation to average wages as physician income in Germany or the United States, and patients have easy access to such technology as computerised axial tomography, organ transplants and bypass surgery.      

The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System

OBJECTIVE: To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States. DATA SOURCE: The 2000 Behavioral Risk Factor Surveillance System. STUDY DESIGN: Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use. PRINCIPAL FINDINGS: Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance. CONCLUSIONS: Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.     

Health insurance coverage among persons with AIDS: results from a multistate surveillance project.

To determine factors associated with health insurance coverage among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 1958 persons 18 years of age or older who were reported to have AIDS in 11 states and cities. Overall, 25% had no insurance, 55% had public insurance, and 20% had private insurance. Factors associated with lack of insurance varied by current employment status. Employed persons with an annual household income of less than $10,000 were 3.6 times more likely to lack insurance than employed persons with a higher income. Unemployed persons diagnosed with AIDS for less than 1 year were two times more likely to lack health insurance than unemployed persons diagnosed for a longer time. Making insurance available to persons identified as most likely to lack insurance should improve access to care for persons with AIDS.     

Reflections on the role of less-than-comprehensive (exclusionary) private health insurance hospital products in the Australian healthcare system

The number of people in Australia that are currently covered by a hospital private health insurance product continues to rise every quarter. In September 2010, for the first time since the introduction of the public universal social insurance scheme, Medicare, more than 10million persons in Australia are covered by private health insurance. Although the number of persons covered by private health insurance continues to grow, the quality and level of cover that members are holding is changing significantly. In an effort to limit premium rises and to reduce the benefits paid for treatment, private health insurers have introduced, and moved a large number of existing members to, less-than-comprehensive private health insurance policies. These policies, known as 'exclusionary' policies, are changing the dynamics of private health insurance in Australia. After examining the emergence and prevalence of these products, this commentary gives three different examples to illustrate how such products are changing the nature of private health insurance in Australia and are now set to create a series of policy issues that will require future attention.     

Erstattungsf?higkeit neuartiger Arzneimitteltherapien

Medical progress poses a new financial challenge for the German statutory health insurance. In order to assure the stability of the German statutory health insurance all services have to be economical, but on the other hand the health care system allows access to new therapy in the ambulant and in-patient sector. This article describes in detail how new therapies are reimbursed.     

Reimbursement of new medical therapy

Medical progress poses a new financial challenge for the German statutory health insurance. In order to assure the stability of the German statutory health insurance all services have to be economical, but on the other hand the health care system allows access to new therapy in the ambulant and in-patient sector. This article describes in detail how new therapies are reimbursed.     

Association between health insurance coverage and uptake of seasonal influenza vaccine in Brazos County,Texas

BackgroundLack of health insurance may limit access to influenza vaccination, resulting in higher risk of infection.MethodsThe Brazos County Health Department obtained medical records summarizing vaccination and health insurance status of all influenza cases occurring in December 2017 (n = 417). The odds of influenza vaccination were estimated for those with public or private health insurance as compared to uninsured individuals using multivariate logistic regression analysis adjusted for age and race.ResultsHealth insurance coverage among Brazos County residents with influenza was 62.4%. Public and private health insurance was associated with higher odds of influenza vaccination compared to no insurance (aOR: 2.05; 95% CI: 1.00–4.21 and aOR: 1.77; 95% CI: 1.07–2.92, respectively), particularly among adults 18–64 years of age.ConclusionsInfluenza vaccination is strongly associated with health insurance. Expansion of programs that facilitate access to health services or provide free influenza vaccines may improve influenza prevention among the uninsured.     

Optional deductibles in social health insurance systems

A fundamental aspect of the German health insurance system is the principle of solidarity. At the same time, it is possible for certain socio-economic groups to opt out of the otherwise compulsory system. To determine whether rates incorporating deductibles are compatible with the principles of solidarity and have the ability to heighten the appeal of statutory health insurance (SHI) funds compared with private health insurance companies, Germany's third largest SHI fund, Techniker Krankenkasse, implemented a pilot scheme involving the use of deductibles. Preliminary scientific evaluations of the pilot scheme indicate three main results for these deductibles: Firstly, they are compatible with the principles of solidarity in the statutory health insurance system; secondly, they provide an effective means of preventing defection to private health insurance companies and thirdly, they reduced the volume of insurance claims (moral hazard).     

Economic burden of multiple sclerosis to the social insurance system in Germany

Aim

This study aims to calculate the cost of illness concerning multiple sclerosis (MS) from the perspective of the German social insurance system.

Subjects and methods

Expenditures for MS (ICD-10 GM: G35) were evaluated retrospectively for the year 2012 from the perspective of the social insurance system. Expenditures from the German statutory health insurance, the Federal statutory pension fund, and statutory long-term care insurances were calculated based on administrative claims of a large nationwide health insurance and statistics from the Federal statutory pension fund. Additionally, expenditures of the long-term care insurances were requested by standardized questionnaire. Costs were extrapolated for all health and statutory long-term care insurances.

Results

In the base case, extrapolated expenditures for German statutory health insurance amount to 1.062 billion €. German statutory pension funds expenses for MS were around 258.700 million € on medical rehabilitation and early retirement. Extrapolated for the whole population insured expenditures of the statutory long-term care insurances on persons with MS were approximately 372.200 million €.

Conclusion

This study delivered important information regarding the economic burden of MS for the social insurance system in Germany. The top-down process of data collection yielded population-based results on the cost of illness.

     

Supplemental insurance and mortality in elderly Americans. Findings from a national cohort

CONTEXT: As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing. OBJECTIVE: To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance. DESIGN: Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures. SETTING: The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index. PARTICIPANTS: A total of 3751 persons aged 65 years and older. MAIN OUTCOMES MEASURES: Five-year mortality rate. RESULTS: After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9). CONCLUSIONS: Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.     

Paying the hospital: American problems and foreign solutions

Hospital financing in the United States suffers from many problems. Many persons lack access because they lack third-party coverage. Among those covered, benefits vary, and persons receive unequal services. Costs are high and are uncontrolled. The hospital is burdened by complicated relations with many payers. In order to cover their costs and earn extra cash, hospitals overcharge the more generous third parties, and recriminations result. All other developed countries have either statutory health insurance, national health services, or full public financing of privately managed hospitals. Whatever the financing method, all countries avoid the problems prevailing in the United States. All citizens are covered, all have access, and hospitals reject no one for financial reasons. All citizens have equal benefits and receive the same basic services. Regulation by government and negotiations with health insurance carriers guarantee the hospital's operating costs to service its catchment area adequately, but also prevent the hospital from installing excessive equipment and excessive staff. Each hospital is paid by all-payer standard rates, administration of reimbursement is simple, and shifting of costs among payers is both unnecessary and administratively impossible. Costs are contained by the total management of the system, not by fragmented efforts by separate insurance carriers. Considerable strategic thinking by government, the providers, and other interest groups sets guidelines for spending levels every year to meet the country's clinical needs but also to stay within its fiscal capacity. Capital investment for new treatments depends on government grants and evaluation of needs.     

Who Opts out of the Statutory Health Insurance? A Discrete Time Hazard Model for Germany

The coexistence of social health insurance and private health insurance in Germany is subject to intense public debate. As only few have the opportunity to choose between the two systems, they are often regarded as privileged by the health insurance system. Applying a hazard model in discrete time, this paper examines the role of incentives set by the regulatory framework and the influence of individual personality characteristics on the decision to opt out of the statutory system. To address potential endogeneity of one of the key explanatory variables, an instrumental variable approach is also applied. The estimation results yield robust evidence on the choice of health insurance type that is consistent with pragmatic decision making, with both incentives set by regulation and personality traits as relevant determinants. Copyright © 2014 John Wiley & Sons, Ltd.     

What people really know about their health insurance: a comparison of information obtained from individuals and their insurers

OBJECTIVES: This study determined the validity of self-reported data on selected health insurance characteristics. METHODS: We obtained telephone survey data on the presence of health insurance, source of insurance, length of time insured, and type of insurance (managed care or fee-for-service) from a random sample of 351 adults in 3 Wisconsin counties and compared findings with data from respondents' health insurers. RESULTS: More than 97% of the respondents correctly reported that they were currently insured. For source of insurance among persons aged 18 to 64 years, sensitivity was high for those covered through private health insurance (93.8%) but low for those covered through public insurance (6.7%). Only 33.1% of the respondents accurately categorized length of enrollment in their current plan. Overall estimates for managed care enrollment were similar for the 2 sources, but individual validity was low: 84.2% of those in fee-for-service believed that they were in managed care. CONCLUSIONS: Information obtained from the general population about whether they have health insurance is valid, but self-reported data on source of insurance, length of time insured, and type of insurance are suspect and should be used cautiously.     

Unwinding the State subsidisation of private health insurance in Ireland

Ireland's private health insurance market provides primarily supplementary health insurance for hospital services, operating alongside a public hospital system to which residents have universal access entitlements, subject to some copayments for those without a medical card. The State subsidises the purchase of private health insurance through measures including tax relief on premiums and not charging the full economic cost for private beds in public hospitals. Furthermore, privately insured patients occupying public beds in public hospitals did not, until 2014, incur charges for such accommodation, apart from modest statutory charges. In the Budget in October 2013, a number of measures were announced that began to unwind these subsidies. Although it was initially feared that these measures would add to premium inflation, leading in turn to further discontinuation of health insurance, the evidence suggests that premium inflation has eased and take-up has stabilised, although some of this may have been due to the introduction of lifetime community rating in May 2015. Nevertheless, it would appear that the restriction on the subsidisation of private health insurance has not had a significant adverse effect on the market, while it has reduced an inequitable cross-subsidy.     

Managing the behavior of the medically insured in Germany: the acceptance of cost-sharing and risk premiums by members of the statutory health insurance

In the course of the conflicts over the reform of statutory health insurance in Germany complaints about moral hazard-behavior on the part of the insured were repeatedly raised and linked to the demand for expanding managerial incentives aimed at reducing the consumption of health care benefits (copayments). However, critics and supporters of managerial incentives mostly neglect the perceptions and dispositions of the insured. In contrast, the article examines how members of the statutory health insurance scheme assess managerial intervention, namely cost-sharing and risk premiums.     

Switching sickness funds and risk compensation mechanisms in the statutory health insurance system in Germany--empirical results from the cooperative health research in the region of Augsburg (KORA)

Since 1996, all citizens of the Federal Republic of Germany who are insured in the statutory health insurance system are entitled to switch their sickness fund. The rationale of this regulation was to strengthen elements of competition in this system in order to stimulate the sickness funds to improve the efficiency of health care and to respond to consumers' preferences. Simultaneously, to avoid the implicit incentives for sickness funds to engage in risk selection, a risk compensation mechanism was introduced, including as morbidity-related risk adjusters age, sex and incapacity to work. Based on the KORA survey S4 (1999/2001) we take the case of switching behaviour in the region of Augsburg, and analyse whether this risk adjustment scheme was working effectively. The results show that persons changing their sickness fund were characterised by a comparatively smaller burden of chronic diseases and by a less frequent utilization of inpatient health care. Under these conditions, differences in the contribution rates do not accurately reflect differences in the performance and efficiency of sickness funds. Moreover, the migration of good risk to sickness funds with favourable contribution rates threatens the principle of financial solidarity. Therefore, the system of risk equalisation has to be developed towards measuring the risk volume borne by the sickness funds more precisely than hitherto.