Does the Universal Health Insurance Program Affect Urban‐Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

Purpose: To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban‐rural inequality in health service utilization among the elderly. Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference‐in‐differences model was employed and estimated by the random‐effect probit method. Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents. Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.     

Health Insurance Coverage and Mortality Revisited

Objective. To improve understanding of the relationship between lack of insurance and risk of subsequent mortality. Data Sources. Adults who reported being uninsured or privately insured in the National Health Interview Survey from 1986 to 2000 were followed prospectively for mortality from initial interview through 2002. Baseline information was obtained on 672,526 respondents, age 18–64 at the time of the interview. Follow‐up information on vital status was obtained for 643,001 (96 percent) of these respondents, with approximately 5.4 million person‐years of follow‐up. Study Design. Relationships between insurance status and subsequent mortality are examined using Cox proportional hazard survival analysis. Principal Findings. Adjusted for demographic, health status, and health behavior characteristics, the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer‐sponsored group insurance at baseline (hazard ratio 1.03, 95 percent confidence interval [CI], 0.95–1.12). Omitting health status as a control variable increases the estimated hazard ratio to 1.10 (95 percent CI, 1.03–1.19). Also omitting smoking status and body mass index increases the hazard ratio to 1.20 (95 percent CI, 1.15–1.24). The estimated association between lack of insurance and mortality is not larger among disadvantaged subgroups; when the analysis is restricted to amenable causes of death; when the follow‐up period is shortened (to increase the likelihood of comparing the continuously insured and continuously uninsured); and does not change after people turn 65 and gain Medicare coverage. Conclusions. The Institute of Medicine's estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.     

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.     

The effect of Taiwan's national health insurance on mortality of the elderly: revisited

A recent paper estimates the effects of Taiwan's National Health Insurance (NHI) on the elderly and concludes that NHI greatly increased the medical care utilization of the elderly but did not reduce their mortality. Using more recent and more accurate mortality data of the same group of elderly, this note re-estimates the NHI effect on mortality and finds that the mortality hazard of the previously uninsured elderly in the post-NHI period was on average 24% lower than it would have been in the absence of NHI. However, the NHI effect on the mortality hazard is only evident in the first 6 years following the enactment of NHI, suggesting that it may be difficult to undo the damage caused by the lack of insurance in early life.     

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.     

HEALTH SERVICE USE AMONG THE PREVIOUSLY UNINSURED: IS SUBSIDIZED HEALTH INSURANCE ENOUGH?

Although it has been shown that gaining Medicare coverage at age 65 years increases health service use among the uninsured, difficulty in changing habits or differences in the characteristics of previously uninsured compared with insured individuals may mean that the previously uninsured continue to use the healthcare system differently from others. This study uses Medicare claims data linked to two different surveys—the National Health Interview Survey and the Health and Retirement Study—to describe the relationship between insurance status before age 65 years and the use of Medicare‐covered services beginning at age 65 years. Although we do not find statistically significant differences in Medicare expenditures or in the number of hospitalizations by previous insurance status, we do find that individuals who were uninsured before age 65 years continue to use the healthcare system differently from those who were privately insured. Specifically, they have 16% fewer visits to office‐based physicians but make 18% and 43% more visits to hospital emergency and outpatient departments, respectively. A key question for the future may be why the previously uninsured seem to continue to use the healthcare system differently from the previously insured. This question may be important to consider as health coverage expansions are implemented. Copyright © 2011 John Wiley & Sons, Ltd.     

The Impact of Health Insurance on Health Outcomes and Spending of the Elderly: Evidence from China's New Cooperative Medical Scheme

This paper investigates the effects of China's New Cooperative Medical Scheme (NCMS) on health outcomes and healthcare expenditure of the elderly in rural China, using panel data from the 2005 and 2008 waves of the Chinese Longitudinal Healthy Longevity Survey. We employ a strategy that combines propensity score matching with a difference‐in‐differences approach to address selection bias. Results show that the NCMS has significantly improved the elderly enrollees' activities of daily living and cognitive function but has not led to better self‐assessed general health status. We find no significant effect of NCMS on mortality for the previously uninsured elderly in NCMS counties, although there is moderate evidence that it is associated with reduced mortality for the elderly enrollees. We also find that the elderly participants are more likely to get adequate medical services when sick, which provides a good explanation for the beneficial health effects of NCMS. However, there is no evidence that the NCMS has reduced their out‐of‐pocket spending. Furthermore, we also find that low‐income seniors benefit more from NCMS participation in terms of health outcomes and perceived access to health care, suggesting that the NCMS helps reduce health inequalities among the rural elderly. Copyright © 2014 John Wiley & Sons, Ltd.     

The healer or the druggist: effects of two health care policies in Taiwan on elderly patients’ choice between physician and pharmacist services

When both physicians and pharmacists in Taiwan prescribed and dispensed drugs, many elderly people considered the two types of health care providers more or less synonymous (i.e., close substitutes). Two policies mandated in the 1990s changed this perception: National Health Insurance (NHI), which provides insurance coverage to all citizens, and a separation policy (SP) that forbids physicians from dispensing and pharmacists from prescribing drugs. The author finds that by providing an economic incentive to the previously uninsured elderly, NHI raised the probability that they would visit physicians, relative to their continuously insured counterparts. In particular, some previously uninsured elderly who once only visited pharmacists were more likely to also visit physicians after NHI was implemented. Following this, the SP made it more likely that all elderly patients would only visit physicians and buy drugs from on-site pharmacists hired by physicians—a result different than its policy goal.      

Smoking Response to Health and Medical Spending Changes and the Role of Insurance

Severe health shocks provide new information about one's personal health and have been shown to influence smoking behaviors. In this paper, we suggest that they may also convey information about the hard to predict financial consequences of illnesses. Relevant financial risk information is idiosyncratic and unavailable to the consumer preceding illness, and the information search costs are high. However, new and salient information about the health as well as financial consequences of smoking after a health shock may impact smoking responses. Using variation in the timing of health shocks and two features of the US health care system (uninsured spells and aging into the Medicare program at 65), we test for heterogeneity in the post‐shock smoking decision according to plausibly exogenous changes in financial risk exposure to medical spending. We also explore the relationship between smoking and the evolution of out‐of‐pocket costs. Individuals experiencing a cardiovascular health shock during an uninsured spell have more than twice the cessation effect of those receiving the illness while insured. For those uninsured prior to age 65 years, experiencing a cardiovascular shock post Medicare eligibility completely offsets the cessation effect. We also find that older adults' medical spending changes separate from health shocks influence their smoking behavior. Copyright © 2016 John Wiley & Sons, Ltd.     

THE DEMAND FOR PREVENTIVE AND RESTORATIVE DENTAL SERVICES

Chronic tooth decay is the most common chronic condition in the United States among children ages 5–17 and also affects a large percentage of adults. Oral health conditions are preventable, but less than half of the US population uses dental services annually. We seek to examine the extent to which limited dental coverage and high out‐of‐pocket costs reduce dental service use by the nonelderly privately insured and uninsured. Using data from the 2001–2006 Medical Expenditure Panel Survey and an American Dental Association survey of dental procedure prices, we jointly estimate the probability of using preventive and both basic and major restorative services through a correlated random effects specification that controls for endogeneity. We found that dental coverage increased the probability of preventive care use by 19% and the use of restorative services 11% to 16%. Both conditional and unconditional on dental coverage, the use of dental services was not sensitive to out‐of‐pocket costs. We conclude that dental coverage is an important determinant of preventive dental service use, but other nonprice factors related to consumer preferences, especially education, are equal if not stronger determinants. Copyright © 2013 John Wiley & Sons, Ltd.     

DID REFORM OF THE NON‐GROUP HEALTH INSURANCE MARKET AFFECT THE DECISION TO BE SELF‐EMPLOYED? EVIDENCE FROM STATE REFORMS IN THE 1990s

This paper estimates whether state‐level implementation of community rating and guaranteed issue regulations in the non‐group health insurance market during the 1990s affected the decision of taxpayers to be self‐employed. Using a panel of tax returns that span 1987–2000, we find no statistically significant effect of the reforms on the propensity to be self‐employed overall, although we find evidence of an increase in self‐employment among older taxpayers and weaker evidence of decreases among younger cohorts. Copyright © 2013 John Wiley & Sons, Ltd.     

Health Insurance and Health Status: Exploring the Causal Effect from a Policy Intervention

Whether health insurance matters for health has long been a central issue for debate when assessing the full value of health insurance coverage in both developed and developing countries. In 2007, the government‐led Urban Resident Basic Medical Insurance (URBMI) program was piloted in China, followed by a nationwide implementation in 2009. Different premium subsidies by government across cities and groups provide a unique opportunity to employ the instrumental variables estimation approach to identify the causal effects of health insurance on health. Using a national panel survey of the URBMI, we find that URBMI beneficiaries experience statistically better health than the uninsured. Furthermore, the insurance health benefit appears to be stronger for groups with disadvantaged education and income than for their counterparts. In addition, the insured receive more and better inpatient care, without paying more for services. Copyright © 2015 John Wiley & Sons, Ltd.     

How Much Risk Pooling Is There in the Individual Insurance Market?

OBJECTIVE: To examine how much pooling of risks occurs among potential purchasers in the individual market, how much pooling occurs among those who purchase coverage, and whether there is greater pooling among longer-term enrollees. DATA SOURCES: The data are administrative records for enrollees in individual insurance plans in California in 2001, and from a survey of Californians enrolled in the individual insurance market and the uninsured. STUDY DESIGN: Logit models were estimated for 5 health outcome measures to compare the insured and uninsured after adjusting for other factors that affect insurance status and health. Multivariate models were also estimated to explore the relationship between health and three measures of pooling in the market: plan type, pricing tier, and the actuarially adjusted premium paid by the enrollee. PRINCIPAL FINDINGS: Those who purchase individual health insurance are in better health than those who remain uninsured. On the other hand, a large share of people with health problems does obtain individual insurance. The distribution of subscribers across plan type and pricing tier varies with their health status. Those in poor health are less likely to purchase low benefit plans. There is less separation of risks for those who become sick after enrollment based on the measure of pricing tier. The distribution of subscribers across plan type for those who have health problems at enrollment and those who become sick differs, but so does the distribution of those who become sick and those who remain healthy. CONCLUSIONS: Despite small differences among the healthy and sick, our results support the conclusion that there is considerable risk pooling in the individual market. To some extent, this pooling occurs because underwriting happens at the time people enroll and there is greater pooling among those who become sick than those who enroll sick. Our results however suggest that health savings accounts may further fragment the market.     

Associations between falls and general health,nutrition, dental health and medication use in Swedish home‐dwelling people aged 75 years and over

The vast majority of elderly people in Sweden live in private homes in their communities for as long as possible. Poor health and a high risk of falls are very common among this group. This cross‐sectional study investigates the association between falls and general health, appetite, dental health, and the use of multiple medications among home‐dwelling men and women aged ≥75 years. Data were collected between October 2008 and March 2009 using a postal questionnaire. A total of 1243 people participated in the questionnaire survey (74% response rate), of which 1193 were included in the analysis. The majority of participants were women (n = 738, 62%). Falls in the previous 12‐month period were reported by 434 (36%) participants. Most fallers (n = 276, 64%) were women. The majority of the fallers lived in a flat (n = 250, 58%). Poor health (aOR: 1.61; CI: 1.34–1.95), poor dental health (aOR: 1.22; CI: 1.07–1.39) and the use of four or more types of medication daily (aOR: 1.13; CI: 1.03–1.25) were significantly associated with falls in all participants. Poor dental health was found irrespectively of living in a flat (aOR: 1.23; CI: 1.04–1.46) or living in a house (aOR: 1.28; CI: 1.02–1.61), and both were significantly associated with falls. The use of more than four different types of medication daily (aOR: 1.25; CI: 1.11–1.41) was associated with falls for those living in a flat. The results highlight that falls are associated with poor general health, poor dental health and the use of four or more types of medication daily. Health professionals should provide health promotion education and investigate dental health and risk factors for oral disease. Likewise, medical and clinical practices of physicians and community care nurses should include assessing the risk of falling, and treatment that predisposes falls.     

Disability in two health care systems: access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities

BackgroundAn overarching question in health policy concerns whether the current mix of public and private health coverage in the United States can be, in one way or another, expanded to include all persons as it does in Canada. As typically high-end consumers of health care services, people with disabilities are key stakeholders to consider in this debate. The risk is that ways to cover more persons may be found only by sacrificing the quantity or quality of care on which people with disabilities so frequently depend. Yet, despite the many comparisons made of Canadian and U.S. health care, few focus directly on the needs of people with disabilities or the uninsured among them in the United States. This research is intended to address these gaps. Given this background, we compare the health care experiences of working-age uninsured and insured Americans with Canadian individuals (all of whom, insured) with a special focus on disability. Two questions for research guide our inquiry: (1) On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access, utilization, satisfaction with, or quality of health care services within or between the United States and Canada? (2) After controlling covariates, when examining each level of disability severity, are there any significant differences in these measures of access, utilization, satisfaction, or quality between U.S. insured and Canadian persons?MethodsCross-sectional data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed with particular attention to disability severity level (none, nonsevere, or severe) among three analytic groups of working age residents (insured Americans, uninsured Americans, and Canadians). Differences in three measures of access, one measure of satisfaction with care, one quality of care measure, and two varieties of physician contacts are compared. Multivariate methods are then used to compare the healthcare experiences of insured U.S. and Canadian persons on the basis of disability level while controlling covariates.ResultsIn covariate-controlled comparisons of insured Americans and Canadians, we find that people with disabilities report higher levels of unmet need than do their counterparts without disabilities, with no difference in this result between the nations. Our findings on access to medications and satisfaction with care among people with disabilities are similar, suggesting worse outcomes for people with disabilities, but few differences between insured U.S. and Canadian individuals. Generally, we find higher percentages who report having a regular physician, and higher contact rates with physicians among people with disabilities than among people without them in both countries. We find no evidence that total physician contacts are restricted in Canada relative to insured Americans at any of the disability levels. Yet we do find that quality ratings are lower among Canadian respondents than among insured Americans. However, bivariate estimates on access, satisfaction, quality, and physician contacts reveal particularly poor outcomes for uninsured persons with severe disabilities in the United States. For example, almost 40% do not report having a regular physician, 65% report that they need at least one medication that they cannot afford, 45% are not satisfied with the way their care is provided, 40% rate the overall quality of their care as fair or poor, and significant reductions in contacts with two types of physicians are evident within this group as well.ConclusionBased on these results, we find evidence of disparities in health care on the basis of disability in both Canada and the United States. However, despite the fact that Canada makes health insurance coverage available to all residents, we find few significant reductions in access, satisfaction or physician contacts among Canadians with disabilities relative to their insured American counterparts. These results place a spotlight on the experiences of uninsured persons with disabilities in America and suggest further avenues for research.     

Continuity of Health Insurance Coverage for Children with Special Health Care Needs

Objectives: To assess the continuity of health insurance coverage and its associated factors for children with special health care needs (CSHCN). Methods: Logistic regression and proportional hazard models were estimated on monthly insurance enrollment for 5594 children in the 1996 Medical Expenditure Panel Survey. CSHCN were identified using a non-categorical approach. Stratified analyses were conducted to determine whether any characteristics differentiated the effects of CSHCN status on children's coverage. Results: In 1996, more than 8% of CSHCN were uninsured for the entire year. For those who were insured in January 1996, 14% lost their coverage by December 1996. CSHCN were more likely than other children to be insured (92% vs. 89%), mainly due to their better access to public insurance (35% vs. 23%). Conversely, CSHCN were less likely than other children to stay insured if they were school-aged, non-Hispanic White, from working, low-income families or the US Midwest region. Higher parental education improved health insurance enrollment for CSHCN, whereas higher family income or having activity limitations protected them from losing coverage. Regardless of CSHCN status, being publicly insured was associated with a higher risk of losing coverage for children. Conclusions: Despite increased health care needs, a considerable proportion of CSHCN is unable to access or maintain coverage. Compared to other children, CSHCN are more likely to have coverage but no more likely to stay insured. Improving continuity of coverage for publicly insured children is needed, especially CSHCN who are more likely to obtain their coverage through public programs.     

VOLUNTARY PRIVATE HEALTH INSURANCE AMONG THE OVER 50s IN EUROPE

Using data from Survey of Health, Ageing and Retirement in Europe (SHARE), we investigate the determinants of voluntary private health insurance (VPHI) among the over 50s in 11 European countries and their effects on healthcare spending. First, we find that the main determinants of VPHI are different in each country, reflecting differences in the underlying healthcare systems, but in most countries, education levels and cognitive abilities have a strong positive effect on holding a VPHI policy. We also analyse the effect of holding a voluntary additional health insurance policy on out‐of‐pocket (OOP) healthcare spending. We adopt a simultaneous equations approach to control for self‐selection into VPHI policy holding and find that, only in the Netherlands, VPHI policyholders have lower OOP spending than the rest of the population, whereas in some countries (Italy, Spain, Denmark and Austria), they spend significantly more. This could be due to not only increased utilisation but also cost‐sharing measures adopted by the insurers to counter the effects of moral hazard and to keep adverse selection under control. Copyright © 2012 John Wiley & Sons, Ltd.     

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.     

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.