The effect of premium changes on SCHIP enrollment duration

Research Objective. To examine the impact of premium changes in Florida's State Children's Health Insurance Program (SCHIP) on enrollment duration.
Data Sources. Administrative records, containing enrollment and demographic data, were used to identify 173,330 enrollment spells for 153,768 children in Florida's SCHIP from July 2002 through June 2004. Health care claims data were used to classify the children's health status.
Study Design. Accelerated failure time models were used to examine the immediate and longer term effects on enrollment length of a temporary premium increase of $15 to $20 per family per month (PFPM) for children in families with income between 101–150 percent of the federal poverty level (FPL) and a permanent premium increase of $15 to $20 PFPM for children in families with 151–200 percent FPL. Health status and sociodemographic variables were included as covariates. Transfers to other public health insurance programs were taken into account.
Principal Findings. Enrollment lengths decreased significantly immediately following the premium increases, with a greater percentage decrease among lower income children (61 percent) than higher income children (55 percent). Enrollment lengths partially recovered in the longer term for both the temporary and permanent changes. Those with significant acute or chronic health conditions had longer enrollment lengths and were less sensitive to premium changes than healthy children.
Conclusions. An increase in the PFPM premium amount had differential effects across income categories and health status levels. Enrollment lengths remained shortened after the premium increase was rescinded for lower income families, suggesting that it may be difficult to reverse the impacts of even a short-term premium increase.     

Medigap premiums and Medicare HMO enrollment

OBJECTIVE: Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans. DATA SOURCES: The analysis is based on a sample of Medicare beneficiaries drawn from the 1996-1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration). STUDY DESIGN: Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums. PRINCIPAL FINDINGS: We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points. CONCLUSIONS: This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies.     

State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment

ObjectiveThe Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers.Study DesignWe compared insurance enrollment in states that did and did not allow tobacco surcharges, using a difference‐in‐difference approach to compare the policy effects among smokers and nonsmokers. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers.Data CollectionWe linked data from two components of the Current Population Survey—the 2015 and 2019 Annual Social and Economic Supplement and the Tobacco Use Supplement, which we combined with data on marketplace plan premiums. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program.Principal FindingsAllowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P < .01) for every 10 percentage point increase in the tobacco surcharge.ConclusionsTobacco use is the largest cause of preventable illness in the United States. State tobacco surcharge policy may have a substantial impact on whether tobacco users choose to remain insured and consequently their ability to receive care critical for preventing and treating tobacco‐related disease.     

医疗保险参保地对老年流动人口健康状况的影响路径研究——基于2015年全国流动人口动态监测调查数据

目的:探析医疗保险参保地点对我国老年流动人口健康状况的影响及路径.方法:利用2015年全国流动人口动态监测调查数据,基于安德森卫生服务利用行为模型,运用路径分析方法,分析医疗保险参保地点对健康状况的影响及路径.结果:在居住地参保有利于流动老人参加健康体检(β=0.60,P<0.001)、小病就医(β=0.33,P<0....     

Integrating risk adjustment and enrollee premiums in health plan payment

In two important health policy contexts – private plans in Medicare and the new state-run “Exchanges” created as part of the Affordable Care Act (ACA) – plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and premium policy in individual health insurance markets based on fitting total plan payments to health plan costs per person as closely as possible. A least squares regression including both health status and variables used in premiums reveals the weights a Regulator should put on risk adjusters when markets determine premiums. We apply the methods to an Exchange-eligible population drawn from the Medical Expenditure Panel Survey (MEPS).     

Will Choice‐Based Reform Work for Medicare? Evidence from the Federal Employees Health Benefits Program

OBJECTIVE:. To examine the effect of premiums and benefits on the health plan choices of older enrollees who choose Federal Employees Health Benefits Program (FEHBP) health plans as their primary payer. DATA SOURCES: Administrative enrollment data from the Office of Personnel Management (OPM) and plan premiums and benefits data taken from the Checkbook Guide to health plans. STUDY DESIGN: We estimate individual plan choice models where the choice of health plan is a function of out-of-pocket premium, actuarial value, plan attributes, and individual characteristics. Plan attributes include plan structure (fee-for-service/preferred provider organization, point-of-service, or health maintenance organization), drug benefit structure, and whether or not the plan covers other types of spending such as dental services and diabetic supplies. The models are estimated by conditional logit. Our study focuses on three populations that currently choose FEHBP as their primary health care coverage and are similar to the Medicare population: current employees and retirees who are approaching the age of Medicare eligibility (ages 60-64) and current federal employees age 65+. Current employees age 65+ are eligible for Medicare, but their FEHBP plan is their primary payer. Retirees and employees 60-64 are not yet eligible for Medicare but are similar in many respects to recently age-eligible Medicare beneficiaries. We also estimate our model for current employees age 55 and younger as a comparison group. DATA COLLECTION METHODS: We select a random sample of retirees and employees age 60-64, as well as all current employees age 65+, from the OPM administrative database for the calendar year 2001. The plan choices available to each person are determined by the plans participating in their metropolitan statistical area. We match plan premium and attribute information from the Checkbook Guide to each plan in the enrollee's list of choices. PRINCIPAL FINDINGS: We find that current workers 65+, 60-64, and non-Medicare eligible retirees are sensitive to variation in plan premiums. The premium elasticities for these groups are similar in magnitude to those of the age 55 and under employee group. Older workers and retirees not yet eligible for Medicare are willing to pay a substantial amount for plans with open provider networks. The willingness to pay for open networks is significantly greater for these groups than for younger employees. Willingness to pay for open network plans varies significantly by income, but varies little by age within group. CONCLUSIONS: Our finding that older workers and non-Medicare eligible retirees are sensitive to plan premiums suggests that choice-based reform of Medicare would lead to cost-conscious choices by Medicare beneficiaries. However, our finding that these groups are willing to pay more for open network plans than younger employees suggest that higher risk individuals may migrate toward higher benefit, higher cost plans. Our findings on the relationship between income and willingness to pay for open network plans suggest that means testing is a viable reform for lowering Medicare program costs.     

Demand for insurance by elderly persons: Private purchases and employer provision

Studies of the demand for health insurance by elderly persons often inadequately address the distinctions between those who receive insurance through a former employer and those who purchase insurance on their own. The failure to distinguish these two modes of supplementing Medicare can lead to an inability to identify the effects of important independent variables. Using data from the Survey of Income and Program Participation this paper examines the demand for employer provided health insurance among retired pensioners using a bivariate probit model with partial observability and compares these results to other models of insurance demand among elderly persons. The results indicate that unobserved factors reducing the probability of being offered employer provided insurance are associated with increased acceptance. A comparison of the employer provided results with results from other models of the demand for privately purchased insurance indicates that different independent variables may determine the probability of having these types of insurance. Previous studies of insurance that have not distinguished between these two types of insurance may not provide reliable estimates of the relationship between independent variables and the probability of insurance coverage.     

The effect of health on acute care supplemental insurance ownership: an empirical analysis

The empirical effect of health status on private insurance ownership is a mixture of the effect of health on the demand for insurance (subjected to adverse selection) and its effect on the insurer's underwriting practice (subjected to risk-selection). Using bivariate partial observability probit models, this paper provides an empirical identification of health effects on the probability of application and on the probability of rejection in the Israeli market for acute care supplemental health insurance. The analysis shows that while the reduced-form health effect on ownership is negligible, the structural effects are sizeable and indicate that sicker individuals are more likely to apply, but are also more likely to be rejected. The policy implications of the above findings are discussed in the context of the Israeli health system.     

The Health Effects of Medicare for the Near-Elderly Uninsured

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

Optimal cost reimbursement of health insurers to reduce risk selection

In the absence of a perfect risk adjustment scheme, reimbursing health insurers' costs can reduce risk selection in community‐rated health insurance markets. In this paper, we develop a model in which insurers determine the cost efficiency of health care and have incentives for risk selection. We derive the optimal cost reimbursement function, which balances the incentives for cost efficiency and risk selection. For health cost data from a Swiss health insurer, we find that an optimal cost reimbursement scheme should reimburse costs only up to a threshold. Copyright © 2010 John Wiley & Sons, Ltd.     

Consumers, health insurance and dominated choices

We analyze employee health plan choices when the choice set offered by their employer includes a dominated plan. During our study period, one-third of workers were enrolled in the dominated plan. Some may have selected the plan before it was dominated and then failed to switch out of it. However, a substantial number actively chose the dominated plan when they had an unambiguously better choice. These results suggest limitations in the ability of health reform based solely on consumer choice to achieve efficient outcomes and that implementation of health reform should anticipate, monitor and account for this consumer behavior.     

The role of consumer knowledge of insurance benefits in the demand for preventive health care among the elderly

In 1992, the United States Centers for Medicare and Medicaid Services (CMS) introduced new insurance coverage for two preventive services--influenza vaccinations and mammograms. Economists typically assume transactions occur with perfect information and foresight. As a test of the value of information, we estimate the effect of consumer knowledge of these benefits on their demand. Treating knowledge as endogenous in a two-part model of demand, we find that consumer knowledge has a substantial positive effect on the use of preventive services. Our findings suggest that strategies to educate the insured Medicare population about coverage of preventive services may have substantial social value.     

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.     

不同时期异位妊娠发病相关因素的变迁

目的:探讨不同时期异位妊娠发病相关因素的变化,为探索切实可行的干预措施提供客观依据。方法:将3个不同时期收治的910例异位妊娠患者分为3组:1985年1月1日～1986年12月31日收治90例为"80年代组;"1995年1月1日～1996年12月31日收治318例为"90年代组;"2005年1月1日～2006年12月31日收治502例为"00年代组",针对不同的发病相关因素(年龄、职业、婚育史、流产史、避孕方式及异位妊娠患者的既往疾病和手术史等)进行回顾性分析。结果:3组患者平均发病年龄差异无统计学意义(P>0.05),发病年龄高峰均为26～30岁,但显示20～25岁年龄段构成比例随年代逐渐增高(P<0.05)。职业分布显示,无业者的比例显著增高,其中学生的比例明显增加。未育患者构成比升高,3组之间差异有统计学意义(P<0.01)。有流产史的患者的比例逐渐上升,以人工流产为主,且3组之间差异有统计学意义(P<0.01)。未避孕的患者构成比显著增高,采用避孕措施的患者构成比下降(P<0.01)。既往史中宫腔手术史在三组中的比例均超过60%并逐渐增高,三组之间差异有统计学意义(P<0.01),其次是盆腔感染史,在三组中的比例逐渐上升(P<0.01)。结论:现阶段异位妊娠患者的发病年龄逐渐年轻化,未婚未育患者比例增加,人工流产史、宫腔手术史、盆腔感染史、吸烟史是目前异位妊娠发病的重要高危因素。