Low-income persons' access to health care: NMCUES Medicaid data

Data from the National Medical Care Utilization and Expenditure Survey (NMCUES) are presented on access to medical care for low-income people in 1980. NMCUES was a national probability household survey jointly sponsored by the National Center for Health Statistics and the Health Care Financing Administration. NMCUES also included four State Medicaid Household Surveys. Data from both the national sample, for all low-income people, and from the four State surveys, for Medicaid people, were included in this analysis. The NMCUES data provided several measures which were previously unavailable on Medicaid experience, in particular, detailed Medicaid eligibility information in combination with income, health status, and health care use. This information can provide a comparison between access to care for those covered by Medicaid, and other low-income persons. In 1980 Medicaid covered a minority of poor and low-income people, only 44 percent of the poor younger than 65 years of age and 38 percent of poor people 65 years of age and older. While almost all elderly had Medicare coverage, about 25 percent of younger low-income people had no form of health insurance, compared with only 9 percent of nonpoor persons who were uninsured. Another measure of access is a regular source of care, the "place where a person goes for health care when sick." In 1980, 15 percent of people younger than 65 who were covered by Medicaid had no regular source of care. This is similar to the rate for the privately insured. However, the types of providers that were cited as the regular source of care differed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Alcohol,drug abuse,and mental health care for uninsured and insured adults

OBJECTIVE: To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems. DATA SOURCES/STUDY SETTING: From a national telephone survey of 9,585 respondents. DESIGN: Follow-up of adult participants in the Community Tracking Study. DATA COLLECTION: Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use. PRINCIPAL FINDINGS: The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured. CONCLUSIONS: The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.     

The demand for preventive and restorative dental services among older adults

Many older Americans have poor access to dental care, resulting in a high prevalence of oral health problems. Because traditional Medicare does not include dental care benefits, only older Americans who are employed, have post‐retirement dental benefits or spousal coverage, or enroll in certain Medicare Advantage plans are able to obtain dental care coverage. We seek to determine the extent to which poor access to dental insurance and high out‐of‐pocket costs affect dental service use by the elderly. Using the 2007–2015 Medical Expenditure Panel Survey and supplemental data on dental care prices, we estimate a demand system for preventive dental services and basic and major restorative services. Selection into dental and medical insurance is addressed using a correlated random effects panel data specification. Consistent with prior studies of the nonelderly population, dental service use was not sensitive to out‐of‐pocket prices. However, private dental insurance increased preventive service use by 25%, and dental coverage through Medicaid increased basic and major service use by 23% and 36%, respectively. The use of services was more responsive to dental insurance for women than men. These estimates suggest that a Medicare dental benefit could significantly increase dental service use by older Americans.     

Inequality and access to health care.

Health services research has laid the groundwork for ongoing policy debates over the shortcomings of the American health care system and the need for the expansion of health insurance protection. In the early 1970s, studies of inequality in access to medical care provided the basis for proposals for national health insurance. The examination of the impact of Medicare and Medicaid demonstrated the critical role of these governmental efforts in reducing inequalities in access to care. By the 1980s the focus of investigation turned to the impact of policies designed to contain the cost of health care on access to medical services by vulnerable populations. Documentation of the negative health outcomes that followed from restrictions on access to care has set the stage for a renewed debate over universal health insurance.     

Racial/ethnic disparities in the use of preventive services among the elderly

OBJECTIVES: Minorities have worse health outcomes compared to whites, which are partially explained by racial/ethnic disparities in use of health services. Less well known, however, are whether these disparities persist among the elderly, the only group that possesses near universal health insurance coverage by Medicare, and how variation in Medicare coverage affects the receipt of preventive services. The scope of racial/ethnic disparities in the use of preventive services in the elderly was assessed, and the impact of the type of health insurance coverage on the use of preventive services was measured. METHODS: Data were derived from the 2001 California Health Interview Survey, a random-digit-dial population-based survey, collected between November 2000 and October 2001. Analysis for this project was conducted in 2004. The association of race/ethnicity and type of health insurance with receipt of preventive services was assessed using bivariate and multivariate logistic regression models. RESULTS: African Americans and Latinos were significantly less likely to be vaccinated for influenza, and Asian Americans were significantly less likely to obtain a mammogram compared to whites, while controlling for other explanatory factors. Moreover, those with Medicare plus Medicaid coverage were significantly less likely to use all four preventive services compared to those with Medicare plus private supplemental insurance. CONCLUSIONS: Despite near-universal coverage by Medicare, racial/ethnic disparities in the use of some preventive services among the elderly persist. Further research should focus on identifying potential cultural and structural barriers to receipt of preventive services aimed at designing effective intervention among high-risk groups.     

Hospitalisation among the elderly in urban China

OBJECTIVES: The aim of this study was to examine the trend of hospitalisation amongst the elderly in urban China and analyse the main socio-economic factors which are affecting the use of inpatient care. METHODS: Data from the Chinese national household health interview surveys conducted in 1993, 1998 and 2003 were analysed. The following variables were selected: gender, health insurance coverage and household income. RESULTS: Elderly people with insurance are more likely to use inpatient services than those who were not insured. Elderly people in the low income group are less likely than ones in the high income group to use inpatient services. Non-hospitalisation is more common amongst elderly women than elderly men and amongst the non-insured. The likelihood of elderly people in the low income groups not using inpatient services has increased dramatically from 12% in 1993 to 134% in 2003. Financial difficulty appeared to be the most common reason for not accessing inpatient care, particularly for elderly people without health insurance. CONCLUSIONS: Elderly people with low income, without health insurance, and women appear to be more vulnerable in their access to inpatient care. Appropriate policies could be developed to protect these groups of people from high health care expenses.     

Hospitalisation among the elderly in urban China

ObjectivesThe aim of this study was to examine the trend of hospitalisation amongst the elderly in urban China and analyse the main socio-economic factors which are affecting the use of inpatient care.MethodsData from the Chinese national household health interview surveys conducted in 1993, 1998 and 2003 were analysed. The following variables were selected: gender, health insurance coverage and household income.ResultsElderly people with insurance are more likely to use inpatient services than those who were not insured. Elderly people in the low income group are less likely than ones in the high income group to use inpatient services. Non-hospitalisation is more common amongst elderly women than elderly men and amongst the non-insured. The likelihood of elderly people in the low income groups not using inpatient services has increased dramatically from 12% in 1993 to 134% in 2003. Financial difficulty appeared to be the most common reason for not accessing inpatient care, particularly for elderly people without health insurance.ConclusionsElderly people with low income, without health insurance, and women appear to be more vulnerable in their access to inpatient care. Appropriate policies could be developed to protect these groups of people from high health care expenses.     

The Influence of Insurance Status and Income on Health Care Use Among the Nonmetropolitan Elderly

The objective of this research is to examine the influence of income and type of insurance coverage on the use of health services among the nonmetropolitan elderly. A model of health services utilization is used as the foundation for examining this issue with data from a telephone survey of a randomly selected sample of residents from four nonmetropolitan counties in Pennsylvania. Results indicated that those elders with Medicaid coverage were less likely to visit a doctor than respondents with private insurance or Medicare only, even after controlling for income and other relevant factors. Further, lower income respondents with Medicare were less likely to visit the dentist than those with private insurance (Medicare does not cover dental care). In contrast, neither income nor insurance predicted hospital use. As such, the health and dental care needs of many lower income nonmetropolitan elders may potentially be going unmet. In general, findings highlight the continued relevance of economic barriers to the use of such services among the nonmetropolitan elderly.     

Paying for national health insurance--and not getting it

The threat of steep tax hikes has torpedoed the debate over national health insurance. Yet according to our calculations, the current tax-financed share of health spending is far higher than most people think: 59.8 percent. This figure (which is about fifteen percentage points higher than the official Centers for Medicare and Medicaid Services [CMS] estimate) includes health care-related tax subsidies and public employees' health benefits, neither of which are classified as public expenditures in the CMS accounting framework. U.S. tax-financed health spending is now the highest in the world. Indeed, our tax-financed costs exceed total costs in every nation except Switzerland. But the sub rosa character of much tax-financed health spending in the United States obscures its regressivity. Public spending for care of the poor, elderly, and disabled is hotly debated and intensely scrutinized. But tax subsidies that accrue mostly to the affluent and health benefits for middle-class government workers are mostly below the radar screen. National health insurance would require smaller tax increases than most people imagine and would make government's role in financing care more visible and explicit.     

Medicare beneficiaries less likely to experience cost- and access-related problems than adults with private coverage

The experiences of people covered by Medicare and those with private employer insurance can help inform policy debates over the federal budget deficit, Medicare's affordability, and the expansion of private health insurance under the Affordable Care Act. This article provides evidence that people with employer-sponsored coverage were more likely than Medicare beneficiaries to forgo needed care, experience access problems due to cost, encounter medical bill problems, and be less satisfied with their coverage. Within the subset of beneficiaries who are age sixty-five or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10?percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems. These results suggest that policy options to shift Medicare beneficiaries into private insurance would need to be attentive to potentially negative insurance experiences, problems obtaining needed care, and difficulties paying medical bills.     

State implementation of the Breast and Cervical Cancer Prevention and Treatment Act of 2000: a collaborative effort among government agencies

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP),administered by the Centers for Disease Control and Prevention through grants to states, tribes, and territories, has successfully provided breast and cervical cancer screening and diagnostic services to low-income women since 1990. On October 24, 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) authorizing states, if they chose, to provide Medicaid coverage for treatment services for women screened under theNBCCEDP. Under BCCPTA, uninsured women younger than age 65 who are screened through the NBCCEDP and found to have breast or cervical cancer (or precancerous conditions) may gain access to Medicaid services for and during their cancer treatment. Implementation of the BCCPTA requires collaboration and coordination among many government agencies, including the Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, state Medicaid directors, and directors of state and tribal grant programs. This article describes the implementation of the program and demonstrates to policy makers that coordinating resources among government agencies can facilitate the rapid adoption of public health programs as pathways for specific populations to gain access to publicly funded health insurance coverage.     

There is little experience and limited data to support policy making on integrated care for dual eligibles

Coordinating care for the nine million elderly or disabled and low-income people who are dually eligible for Medicare and Medicaid is a pressing policy issue. To support the debate over this issue, we synthesized public data on how services are provided to dual eligibles receiving covered benefits in both programs. Our analysis confirmed that most dual-eligible beneficiaries receive benefits separately for each program through fee-for-service arrangements. Their enrollment in Medicare and Medicaid managed care is growing but still low, with highly uneven experiences across states. Few states or health plans have experience with coordinating care for dual eligibles within an integrated plan. These findings reinforce the need for caution in considering policies that would rapidly give states the responsibility for coordinating dual eligibles' care and coverage. We also found data gaps that warrant prompt attention in order to provide national-level oversight and improve the evidence base for debating and tracking policy changes.     

Access to specialty care and medical services in community health centers

Although community health centers (CHCs) provide primary health services to the medically underserved and poor, limited access to off-site specialty services may lead to poorer outcomes among underinsured CHC patients. This study evaluates access to specialty health services for patients receiving care in CHCs, using a survey of medical directors of all federally qualified CHCs in the United States in 2004. Respondents reported that uninsured patients had greater difficulty obtaining access to off-site specialty services, including referrals and diagnostic testing, than did patients with Medicaid, Medicare, or private insurance.     

Business opportunities in transforming health care: an interview with William W. McGuire

After a spate of high-profile acquisitions including Oxford Health Plans, UnitedHealth Group (UHG) covers twenty-two million Americans in insured and self-insured health plans and tens of millions more through specialty products. Bill McGuire describes his strategy of growth through acquisition and through diversification into Medicaid managed care, the individual insurance market, and services for the elderly under the Medicare Modernization Act of 2003. He sees business and public policy opportunities in the unjustifiable variation in cost and quality across the health care spectrum and proposes a framework of basic insurance benefits for all Americans, with options for people to purchase additional benefits with their own money.     

Pennsylvania's medically uninsured population: findings from a statewide survey

Pennsylvania is currently considering legislative options to expand coverage and improve access to medical care for state residents who lack health insurance. Relevant data are presented from a telephone survey of 10,809 Pennsylvania households. Almost nine percent (8.5%) of the state's population lacks health insurance, representing over one million people. Those most likely to be uninsured are children and young adults, non-whites and the poor. A substantial number of poor people are not covered by the state's Medicaid program. The uninsured report poorer health status, more obstacled to receiving care and greater use of hospital services for primary care.     

Cost sharing, supplementary insurance, and health services utilization among the Medicare elderly.

This paper investigates the extent to which private supplementary insurance and Medicaid, which vitiate the effect of Medicare cost-sharing, encourage elderly beneficiaries to seek additional medical care. A multivariate model of health services utilization is estimated with the Tobit technique, using the 1976 Health Interview Survey. We find that either private or public supplementation induces greater use of hospital and physician services, though in amounts that vary considerably according to health status. The paper closes with observations on cost savings brought about by Medicare cost-sharing and some implications for equity among beneficiaries.     

Who will provide preventive services? The changing relationships between medical care systems and public health agencies in health care reform.

Health care reform in the United States will likely attempt to expand the health insurance coverage to uninsured groups, control costs, enhance quality, and expand access to care. Preventive services will be assigned to the medical care system, while new roles and responsibilities will be defined for public health agencies. The clinical preventive services likely required are examined in a population of 44,565 persons residing in Otsego County, New York. Expansion of preventive services to Medicaid requests and the uninsured will require considerable resource expenditure to correct the current deficit in preventive services received by these groups. Moreover, the uninsured and Medicaid recipients have high levels of risk behaviors, identifying a need for health education services effective to that population subgroup. The transfer of responsibilities for clinical preventive services to the medical care system may free up resources for public health agencies to focus on other initiatives such as disease surveillance, health education, and quality assurance. New interrelationships, some cooperative and some adversarial, are likely to emerge, due to a closer working relationship between the medical care system and public health agencies than previously seen in American health care.     

Web Chatter Before and After the Women's Health Initiative Results: A Content Analysis of On-line Menopause Message Boards

People aging into Medicare need to choose a health plan. Several challenges exist for consumers in choosing a Medicare health plan, including limited knowledge of Medicare, limited experience in using comparative health plan quality information, and limited experience and ability to pull together and use plan information from different sources like employers and the Medicare program. The Choose with Care System was developed to help consumers aging into Medicare make informed Medicare health plan choices. Choose with Care is an innovative decision support tool for employers to use to assist people approaching age 65 to learn about their Medicare health plan options and how to incorporate information on the quality of care and services offered by health plans into their choices. Employers are the targeted channel for distributing the Choose with Care materials because they are one of the most recognized and accessible formal intermediaries for information about health insurance. We used multiple methods to test the Choose with Care products. Product testing showed that the Choose with Care materials increase older consumers' knowledge of Medicare and how it relates to retiree health insurance and improves their comprehension and use of comparative quality information when choosing a health plan.     

The "choose with care system" - development of education materials to support informed Medicare health plan choices

People aging into Medicare need to choose a health plan. Several challenges exist for consumers in choosing a Medicare health plan, including limited knowledge of Medicare, limited experience in using comparative health plan quality information, and limited experience and ability to pull together and use plan information from different sources like employers and the Medicare program. The Choose with Care System was developed to help consumers aging into Medicare make informed Medicare health plan choices. Choose with Care is an innovative decision support tool for employers to use to assist people approaching age 65 to learn about their Medicare health plan options and how to incorporate information on the quality of care and services offered by health plans into their choices. Employers are the targeted channel for distributing the Choose with Care materials because they are one of the most recognized and accessible formal intermediaries for information about health insurance. We used multiple methods to test the Choose with Care products. Product testing showed that the Choose with Care materials increase older consumers' knowledge of Medicare and how it relates to retiree health insurance and improves their comprehension and use of comparative quality information when choosing a health plan.