The spillover effects of health insurance benefit mandates on public insurance coverage: Evidence from veterans

This study examines how regulations in private health insurance markets affect coverage of public insurance. We focus on mental health parity laws, which mandate private health insurance to provide equal coverage for mental and physical health services. The implementation of mental health parity laws may improve a quality dimension of private health insurance but at increased costs. We graphically develop a conceptual framework and then empirically examine whether the regulations shift individuals from private to public insurance. We exploit state-by-year variation in policy implementation in 1999–2008 and focus on a sample of veterans, who have better access to public insurance than non-veterans. Using data from the Current Population Survey, we find that the parity laws reduce employer-sponsored insurance (ESI) coverage by 2.1% points. The drop in ESI is largely offset by enrollment gains in public insurance, namely through the Veterans Affairs (VA) benefit and Medicaid/Medicare programs.     

Does supplemental private insurance affect care of Medicare recipients hospitalized for myocardial infarction?

OBJECTIVES: We sought to determine whether supplemental private insurance coverage among Medicare recipients alters patterns of health care or outcomes associated with acute myocardial infarction. METHODS: Medicare patients hospitalized after a myocardial infarction were identified from New York City hospitalization records. Patients who had only Medicare coverage were compared with those who had supplemental private or public insurance coverage. RESULTS: Patients with supplemental private insurance exhibited increased rates of revascularization and decreased rates of in-hospital mortality relative to patients with either Medicare only or Medicare and public insurance. Moreover, Blacks and women were less likely to undergo revascularization and exhibited higher in-hospital mortality rates. CONCLUSIONS: Despite Medicare, private insurance coverage appears to influence the likelihood of coronary revascularization among older patients hospitalized for acute myocardial infarction.     

Charges and charge coverage in the treatment of HIV/AIDS patients in a rural southern state

In Mississippi it was not known where Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Disease Syndrome (AIDS) persons receive care, what type of care is available to them, and how care is financed. To ascertain inpatient treatment charges of HIV/AIDS patients, a medical record review was conducted at 10 priority hospitals distributed across Mississippi. One-hundred fifty-six (156) patient records were randomly selected from a population of persons with HIV/AIDS. A total of 3,865 patient days was recorded for all hospitals. Available overall hospital charges per paid day ranged from +401.63 to +1,261.34, with an average charge of +741.65 per day. Average length of stay was 25 days. Average charge per hospitalization per patient totaled +18,541. Concerning source of payment, 44.8% of the patients had private insurance, 29.9% listed Medicaid as their payment source, 7.8% were on Medicare, 1.3% had supplemental insurance, and 16.2% of patients reviewed had no payment source. Based on this review, it is evident that the number of AIDS patients covered by private health insurance will continue to decline and the payment responsibilities will continue to shift to public supported programs. Acquired immunodeficiency syndrome brings attention to the weakness of Mississippi's health care financing system and will continue to force consideration of alternative financing mechanisms.     

Public option and private profits

Background

The debate on US healthcare reform has largely focused on the introduction of a public health plan option. While supporters stress various beneficial effects that would arise from increased competition in the health insurance market, opponents often contend that a public plan would drive insurers out of the market and potentially lead to the ‘collapse’ of the private health insurance industry.

Objectives

To contribute to the US healthcare reform debate by inferring, from financial market data, the effect that the public option is likely to have on the private health insurance market.

Methods

The study utilized daily data on the price of a security that was traded in a prediction market from June 2009 and whose pay-off was tied to the event that a federal government-run healthcare plan — the ‘public option’ - would be approved by 31 December 2009 (100 daily observations). These data were combined with data on stock returns of health insurance companies (1500 observations from 100 trading days and 15 companies) to evaluate the expected effect of the public option on private health insurers. The impact on hospital companies (1000 observations) was also estimated.

Results

The results suggested that daily stock returns of health insurance companies significantly responded to the changing probability regarding the public option. A 10% increase in the probability that the public option would pass, on average, reduced the stock returns of health insurance companies by 1.28% (p < 0.001). Hospital company stock returns were also affected (0.9% reduction; p < 0.001).

Conclusions

The results reveal the market expectation of a negative effect of the public option on the value of health insurance companies. The magnitude of the effect suggests a downward adjustment in the expected profits of health insurers of around 13%, but it does not support more calamitous scenarios.     

Insurance Instability and Its Impact on Care of Young Adult Survivors of Pediatric Cancer: A Project Forward Study

By 2020, there will be more than 500,000 childhood cancer survivors (CCS) in the United States. CCS experience disparities in economic, social, and health-related quality of life outcomes, and these disparities are magnified for CCS who are uninsured. Access to long-term follow-up (LTFU) care for surveillance, preventive care, and treatment of late effects for survivors are vital to improve long-term outcomes. Inadequate insurance coverage, high out-of-pocket costs, and lack of perceived need for care have been shown to affect access to LTFU care among CCS. The objectives of this study were to (1) assess insurance instability longitudinally and describe patient factors that correlate with instability and (2) examine whether insurance instability and financial or patient factors influence access to LTFU care. Project Forward was a population-based, observational study of CCS in Los Angeles County using California Cancer Registry (CCR) data to identify participants who completed a survey. Change in insurance coverage was assessed at diagnosis using CCR data and at survey and its impact on LTFU care. Those who experienced any change in insurance coverage (“insurance instability”) were set equal to one. Multivariable logistic regression models incorporating survey nonresponse weights were used to estimate the change in the marginal predicted probabilities of insurance instability and LTFU care, adjusted for demographic, socioeconomic, and clinical covariates and clustered by treating hospital. Study participants were diagnosed with cancer between the ages of 0 and 19 while living in Los Angeles County between 1996 and 2010 and were older than 21 at the time of survey, from 2015 to 2017 (N = 1106). Almost half (48%; N = 529) of participants experienced insurance instability from diagnosis to survivorship, while 577 did not. After adjusting for demographic, socioeconomic, and clinical covariates, the multivariable model predicting insurance instability indicated that being uninsured at diagnosis or at survey increased the probability of instability by 37% (P < .001) and 58% (P < .001), respectively, in comparison with those with private insurance. The multivariable model predicting LTFU care indicated that those who experienced insurance instability decreased the probability of LTFU care by 5% (P < .05), in comparison with those who did not experience instability. When compared to those with private insurance coverage at diagnosis, participants who were covered by Medicaid, Medicare, or Indian Health Service plans at diagnosis were more likely to participate in LTFU care by 5% (P < .05); however, those who were uninsured at the time of the survey were less likely to participate in LTFU care by 10% (P < .05). CCS who were uninsured at diagnosis or survivorship were more likely to experience insurance instability. Insurance instability and being uninsured during survivorship were negatively associated with access to LTFU care; however, those with public insurance coverage at diagnosis were positively associated with access to LTFU care. Reducing insurance instability for CCS will improve access to LTFU care. This insight is key to improving health, reducing unnecessary and inappropriate health care use, and decreasing costs, while promoting services that can preserve and improve health for CCS. The study was funded by the National Institutes of Health.     

An economic history of Medicare part C

Context: Twenty‐five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee‐for‐service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer‐sponsored health insurance with managed care over the same time period. Findings: Beneficiaries’ access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high‐quality care, and to save Medicare money.     

Shortcomings in public and private insurance coverage of diabetes self-management education and support

The objective of this study is to present preliminary data to characterize public and private insurance coverage for diabetes self-management education (DSM Education) and diabetes self-management support (DSM Support). Representatives from Medicaid and 2 private insurance providers in 10 states provided coverage information for their insurance plans. Two states (the most populous state from the East and West coasts) were sampled purposively and 8 additional states from 4 geographic regions (northeast, southeast, northwest, southwest) were sampled at random. Representatives from each private insurer described both a premium and basic coverage plan. Thus, 10 Medicaid programs and 40 private insurance plans were represented. Information about Medicare coverage was accessed from publicly available documents. Restricted by physician certification of patient eligibility, Medicare coverage included 10 hours of DSM Education plus 3 hours of medical nutrition therapy (MNT) within a continuous 12-month period, and 4 hours of follow-up (2 hours DSM Education and 2 hours MNT) for each subsequent year. Only 22 of 40 sampled private insurance and 5 of 10 Medicaid plans covered DSM Education, which ranged from 7 to 20 hours of education per year. Medicaid and private plans often limited the amount of DSM Education or required patients to obtain a physician certification of eligibility. Other than on-demand access features, coverage of DSM Support was minimal. Public and private insurance coverage of DSM Education was neither widespread nor uniform, while coverage of DSM Support was scarce.     

Public and private health insurance premiums: how do they affect the health insurance status of low-income childless adults?

The Patient Protection and Affordable Care Act (ACA) will substantially increase public health insurance eligibility and alter the costs of insurance coverage. Using Current Population Survey (CPS) data from the period 2000-2008, we examine the effects of public and private health insurance premiums on the insurance status of low-income childless adults, a population substantially affected by the ACA. Results show higher public premiums to be associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured, while increased private premiums decrease the probability of having private insurance. Eligibility for premium assistance programs and increased subsidy levels are associated with lower rates of uninsurance. The magnitudes of the effects are quite modest and provide important implications for insurance expansions for childless adults under the ACA.     

Multiplicity of skin cancers in Queensland and their cost burden to government and patients

Objective: To determine the cost burden to government and patients for individuals with multiple skin cancers. Methods: We used self‐reported baseline data on socio‐demographics, phenotype and sun exposure behaviours from participants in the QSkin Sun and Health Study with at least one histopathologically confirmed keratinocyte cancer or melanoma (n=5,673). Linkage to Australian Medicare data (2011–2014) provided resource data and government and out‐of‐pocket patient costs. Generalised linear models examined costs by frequency of skin cancer groups separately for melanoma and keratinocyte cancer. Results: Over three years, 539 participants were diagnosed with melanoma (11% had ≥2 melanomas) and 5,134 participants were treated for keratinocyte cancers (10% had ≥6). Median Medicare costs per person were $1,325 (maximum $6,117) for ≥2 melanomas and $2,126 (maximum $54,618) for ≥6 keratinocyte cancers. Increased costs were associated with private health insurance. Conclusions: Individuals who are multiply affected by skin cancers are relatively common and the accompanying individual and government cost burden can be substantial. These findings support skin cancer being classified as a chronic disease. Implications for public health: Over time, the economic burden for skin cancer for individuals and health providers is high and investment in prevention remains important from an economic viewpoint.     

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.     

患者选择公立或民营医院就诊的影响因素分析——以中老年患者为例

本文采用二项Logistic回归模型,利用2011年"中国健康与养老追踪调查"(CHALRS)数据,对中老年就诊患者选择公立或民营医院的影响因素进行分析。研究发现自评健康、就诊咨询、使用基本医疗保险报销等因素影响显著。健康存量越小、有就诊咨询需求、使用基本医疗保险报销的患者选择公立医院的概率相对较高。说明中老年就诊患者在处理疾病风险时更信赖公立医院,医保定点医院主要集中在公立医院,进一步推动了患者选择公立医院就诊。建议加强对老年性疾病的预防和控制;提高医院的咨询服务水平;加强对民营医院的扶持,放开民营医院的价格限制,调整医保定点医院的准入机制;加强行业监管和信息公开。     

Why more cost-sharing won't slow Medicare spending

In considering ways to slow the growth in Medicare expenditures, policymakers have concluded that increasing point-of-service cost-sharing for patients will reduce demand for health services. Under the current system, Medicare beneficiaries faced with increased cost-sharing can reduce their demand for services or purchase additional private insurance. New data from the 1991 Medicare Current Beneficiary Survey show that high-income persons protect themselves from out-of-pocket costs by purchasing private supplemental insurance. Surprisingly, the data also reveal that many low-income persons also purchase private insurance, demonstrating that the elderly--whatever their income level--consider supplementary insurance more of a necessity than a luxury. Thus, it appears that increased beneficiary cost-sharing would have a limited effect on Medicare spending growth.     

Health insurance coverage among disabled Medicare enrollees

In this article, we use the Survey of Income and Program Participation to identify patterns of non-Medicare insurance coverage among disabled Medicare enrollees. Compared with the aged, the disabled are less likely to have private insurance coverage and more likely to have Medicaid. Probit analysis of the determinants of private insurance for disabled Medicare enrollees shows that income, education, marital status, sex, and having an employed family member are positively related to the likelihood of having private health insurance, whereas age and the probability of Medicaid enrollment are negatively related to this likelihood.     

The role of retiree health insurance in the early retirement of public sector employees

Most government employees have access to retiree health coverage, which provides them with group health coverage even if they retire before Medicare eligibility. We study the impact of retiree health coverage on the labor supply of public sector workers between the ages of 55 and 64. We find that retiree health coverage raises the probability of stopping full time work by 4.3 percentage points (around 38 percent) over two years among public sector workers aged 55–59, and by 6.7 percentage points (around 26 percent) over two years among public sector workers aged 60–64. In the younger age group, retiree health insurance mostly seems to facilitate transitions to part-time work rather than full retirement. However, in the older age group, it increases the probability of stopping work entirely by 4.3 percentage points (around 22 percent).