The Relation Between Health Insurance and Health Care Disparities Among Adults With Disabilities

Objectives. We examined disparities among US adults with disabilities and the degree to which health insurance attenuates disparities by race, ethnicity, and socioeconomic status (SES).Methods. We pooled data from the 2001–2007 Medical Expenditure Panel Survey on individuals with disabilities aged 18 to 64 years. We modeled measures of access and use as functions of predisposing, enabling, need, and contextual factors. We then included health insurance and examined the extent to which it reduced observed differences by race, ethnicity, and SES.Results. We found evidence of disparities in access and use among adults with disabilities. Adjusting for health insurance reduced these disparities most consistently for emergency department use. Uninsured individuals experienced substantially poorer access across most measures, including reporting a usual source of care and experiencing delays in or being unable to obtain care.Conclusions. Although health insurance is an important enabling resource among adults with disabilities, its effect on reducing differences by race, ethnicity, and SES on health care access and use was limited. Research exploring the effects of factors such as patient–provider interactions is warranted.Continuing its emphasis on reductions in health care disparities, Healthy People 2020 identifies the elimination of health disparities as 1 of 4 overarching goals.1 Congress has charged the Agency for Healthcare Research and Quality (AHRQ) with tracking disparities in health care access and quality among racial, ethnic, and socioeconomic groups, as well as for priority populations. In April 2012, AHRQ released its ninth report, finding that, although there was evidence of improvements in quality of care, health care access and quality are suboptimal, particularly for individuals who are racial/ethnic minorities or of lower socioeconomic status (SES).2An estimated 1 in 5 noninstitutionalized individuals in the United States experiences a disability.3 Although individuals with disabilities have been identified as a priority population by Congress,2 examining disparities among those with disabilities has garnered less attention. There is evidence that individuals with disabilities receive fewer preventive and treatment services than individuals without disabilities.4–7 Individuals with disabilities are more likely to report cost as a barrier to care,4,8 to report higher out-of-pocket costs,9 and to report unmet need for medical care.8Individuals with disabilities are disproportionately racial/ethnic minority and of lower SES. Rates of disability are higher for Blacks (22.2%) than for Hispanics (17.8%) and Whites (17.4%).3 Using data from the American Community Survey, Erickson and Lee10 found prevalence of disability to decline with increasing income. Disability is also associated with educational attainment. Substantially more people without a disability (30.8%) had a bachelor’s degree or higher than people with a disability (12.5%). Limited work has focused on disparities by race and SES on health care access and use among individuals with disabilities.11Health insurance provides an essential link to health services and outcomes,12,13 attenuating but not eliminating disparities by race and SES in the general population.14 Data from the 2010 American Community Survey indicate that, nationally, 82.1% of working-age individuals with disabilities had health insurance, compared with 78.2% among working-age individuals without disabilities.15 Nationally, 17.9% of working-age adults with disabilities were uninsured, but there was substantial state variability. Adults with disabilities are much more likely to have public, relative to private, coverage—50.5% public and 43% private coverage nationally in 2010 (some individuals have both public and private coverage). Research has rarely examined the extent to which health insurance coverage reduces potential disparities by race, ethnicity, and SES among individuals with disabilities. Thus, we extended the research on disparities among individuals with disabilities by examining whether minority and lower-SES adults with disabilities experience disparate access to and use of health care services.     

Rates of Insurance for Injured Patients Before and After Health Care Reform in Massachusetts: A Possible Case of Double Jeopardy

Objectives. We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform.Methods. We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004–2005) and after (2009–2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes.Results. Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% (P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients.Conclusions. Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in “double jeopardy” of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate.The burden of uncompensated care on the health care system and risk of personal financial ruin of uninsured individuals who experience a health shock (unexpected serious illness or accident)1 are among the leading arguments in favor of an individual mandate in the 2010 federal health care reform legislation. Modeled after the Massachusetts health care reform implemented in 2006,2,3 comprehensive federal health care reform is presumed to result in the greatest gains of health insurance among able-bodied adults aged 18 to 64 years mandated to enroll in subsidized or unsubsidized insurance plans. Although opponents of an individual mandate may argue that otherwise healthy adults with minimal health care needs should not be required to purchase health insurance,4 no individual, irrespective of age or baseline health status, is immune to risk of injury. Trauma represents a significant health shock experienced by able-bodied, community-dwelling adults aged 18 to 64 years and is a leading cause of death and disability in this demographic group.5,6Another federal mandate enacted by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency care to individuals experiencing a health shock, regardless of whether they are insured.7 Not surprisingly, emergency department (ED) resource use in response to health shocks has been shown to be independent of insurance status.8 In Massachusetts, implementation of health care reform did not affect trends in ED use.9 Patient care in the face of a health shock, however, rarely stops in the ED.When injured patients without insurance arrive at a trauma center, they are not only stabilized, as mandated by EMTALA, but also provided comprehensive trauma care as required of verified trauma centers in our proven national and state-level trauma systems.10,11 Even after stabilization, injured patients often cannot be released because they are critically ill or require treatments (e.g., intravenous antibiotics, chest tube monitoring) that for practical reasons or out-of-pocket costs cannot be rendered outside of the hospital. These uninsured patients are often provided ongoing free care at the presenting hospital or transferred once stabilized to safety-net hospitals that typically do not refuse patients on the basis of insurance.12 Depending on governance structure (publicly managed, publicly funded, or private nonprofit), 5% to 16% of patients at safety-net hospitals are provided free care.13 Data from the 2004 Medical Expenditure Panel Survey suggested that only 35% (95% confidence interval [CI] = 26%, 45%) of charges to uninsured patients for non–life-threatening emergency services were recouped by hospitals.14 In the case of injuries too severe to be treated and released, the burden of the cost of care is therefore assumed one way or another by the health care system, raising costs for everyone. Furthermore, uninsured patients often incur greater costs of care compared with their insured counterparts, as they must remain hospitalized until they can be safely discharged home because no similar laws mandate uncompensated home health services, skilled nursing, or rehabilitation often required by medically stable injured patients.15–17Proponents of an individual mandate might presume that improved rates of insurance in the general population would result in fewer uninsured injured patients treated at trauma centers, but the effect of an individual mandate on insurance coverage among injured patients is unknown. Therefore, the effects of health care reform on the burden of uncompensated trauma care in Massachusetts may have important national implications on the potential effect of national health care reform on our nation’s trauma system. We undertook this study to determine how an individual mandate affected insurance status among injured Massachusetts residents. We hypothesized that we would have treated fewer uninsured patients after implementation of Massachusetts health care reform. Presumably, the individual mandate would have resulted in rates of insurance among our patients as observed statewide.     

The Impact of Increasing Health Insurance Coverage on Disparities in Mortality: Health Care Reform in Colombia, 1998–2007

Objectives. We examined the impact of expanding health insurance coverage on socioeconomic disparities in total and cardiovascular disease mortality from 1998 to 2007 in Colombia.Methods. We used Poisson regression to analyze data from mortality registries (633 905 deaths) linked to population census data. We used the relative index of inequality to compare disparities in mortality by education between periods of moderate increase (1998–2002) and accelerated increase (2003–2007) in health insurance coverage.Results. Disparities in mortality by education widened over time. Among men, the relative index of inequality increased from 2.59 (95% confidence interval [CI] = 2.52, 2.67) in 1998–2002 to 3.07 (95% CI = 2.99, 3.15) in 2003–2007, and among women, from 2.86 (95% CI = 2.77, 2.95) to 3.12 (95% CI = 3.03, 3.21), respectively. Disparities increased yearly by 11% in men and 4% in women in 1998–2002, whereas they increased by 1% in men per year and remained stable among women in 2003–2007.Conclusions. Mortality disparities widened significantly less during the period of increased health insurance coverage than the period of no coverage change. Although expanding coverage did not eliminate disparities, it may contribute to curbing future widening of disparities.Recent health care reform in the United States has sparked debate on the potential impact of expanding health insurance coverage on access to care and disparities in health care.1 People with lower socioeconomic status are at increased risk of many conditions and are therefore more likely to benefit from an expansion in health insurance coverage.1 Previous observational studies in the United States have suggested that a lack of health insurance was associated with an increased risk of subsequent mortality in all socioeconomic groups.2 However, little is known about the impact of health insurance coverage on socioeconomic disparities in mortality following a major expansion in insurance coverage. In 1993, the Colombian government implemented a major health care reform that introduced mandatory health insurance.3 As a result, coverage increased from 47% in 19944 to 98% in 2010.5 Although the social and economic context of Colombia differs substantially from that in the United States, lessons from the Colombian reform can shed light on the potential impact of increased health insurance coverage on health disparities in the United States and middle-income countries currently expanding insurance coverage.A desirable outcome of coverage expansion is that it will have a larger impact on the health of the poor and will contribute to a reduction in health disparities.3,6 The reform in Colombia established a scheme of subsidies targeted to the poor, assigning citizens to 2 schemes on the basis of income: (1) the contributory scheme, which covers workers and their families with an income above the cut-off and is financed through payroll and employer’s contributions, and (2) the subsidized scheme, which covers the poor as identified through a proxy means test.6In the poorest income quartile, health insurance coverage increased from 6% in 1993 to more than 70% in 2007,6 an increase attributable to the subsidized scheme.5 Increased coverage among the poor is expected to improve health outcomes by ensuring timely care and bringing them into closer contact with the health care system.7 However, the reform also increased the complexity of the system potentially leading to delays in some types of care8 and reducing spending in prevention and public health.9 Previous dynamic simulations for the United States have suggested that expanding health insurance coverage is cost-effective, but failing to also expand the primary care capacity for the disadvantaged could lead to increasing health disparities.10 There have been no empirical studies examining these issues in the context of a major health care reform.Most previous studies have focused on the impact of health care reform on utilization and access to health care services, with only some studies examining the impact on population health.7,11–13 A recent review of available evidence concluded that expanding health insurance coverage generally improves access to care and population health particularly for lower income groups, but health gains may be dependent on the institutional framework and governance arrangements.14 On the other hand, the World Health Organization Commission on Social Determinants of Health concluded that, although inequity in health care is critical, the largest burden of illness arises in large part because of the conditions in which people are born, grow, live, work, and age.15We examined whether expanding health insurance coverage is associated with trends in socioeconomic disparities in mortality in the aftermath of the health care reform in Colombia. Findings from this study are of potential interest to the United States and middle-income countries that have recently implemented reforms to achieve universal access. We hypothesized that expanding health insurance coverage will contribute to curbing unfavorable trends in mortality disparities. To assess the impact of this expansion, we examined trends in mortality disparities by educational level separately for 2 divergent periods. In 2002, a process of decentralization led to a sharp increase in resource allocation to the subsided scheme in regional areas.16 As a result, whereas in the period 1998–2002 there was a moderate increase in total health insurance coverage (coverage went from 59.8% in 1998 to 64.1% in 2002), thereafter total coverage increased rapidly from 65.9% (2003) to 92.5% (2007; Figure 1). This corresponds to a statistically significant increase of 5.1% per year (P < .001) in the period 2003–2007. As illustrated in Figure 1, this increase was driven by a particularly steep increase in affiliates to the subsidized scheme in 2003–2007 (15.1% per year; P < .001), as opposed to a much smaller increase in the period 1998–2002 (6.4% per year; P < .001), suggesting that it may have particularly reached the lower socioeconomic groups. The discrepancy in health insurance coverage trends between these 2 periods thus provides a natural experiment to examine the impact of health insurance coverage on socioeconomic disparities in mortality.Open in a separate windowFIGURE 1—Percentage of population with health insurance coverage: Colombia, 1998–2007.Note. Other schemes include primarily members of the military and teacher and oil workers syndicate members.Source. Annual reports of the Ministry of Health and Social Protection.5,17–19Our specific aim was to evaluate to what extent increased health insurance coverage has contributed to diminishing socioeconomic inequalities in mortality in Colombia. If socioeconomic differences in mortality were responsive to increased health insurance coverage, we would expect a more favorable trend in socioeconomic differences in mortality during the second than the first period. If increased insurance coverage had no impact on socioeconomic disparities in mortality, we would expect similar trends in socioeconomic disparities in mortality between the 2 periods.     

Insurance Continuity and Human Papillomavirus Vaccine Uptake in Oregon and California Federally Qualified Health Centers

Objectives. We examined the association between insurance continuity and human papillomavirus (HPV) vaccine uptake in a network of federally qualified health clinics (FQHCs).Methods. We analyzed retrospective electronic health record data for females, aged 9–26 years in 2008 through 2010. Based on electronic health record insurance coverage information, patients were categorized by percent of time insured during the study period (0%, 1%–32%, 33%–65%, 66%–99%, or 100%). We used bilevel multivariable Poisson regression to compare vaccine-initiation prevalence between insurance groups, stratified by race/ethnicity and age. We also examined vaccine series completion among initiators who had at least 12 months to complete all 3 doses.Results. Significant interactions were observed between insurance category, age, and race/ethnicity. Juxtaposed with their continuously insured peers, patients were less likely to initiate the HPV vaccine if they were insured for less than 66% of the study period, aged 13 years or older, and identified as a racial/ethnic minority. Insurance coverage was not associated with vaccine series completion.Conclusions. Disparities in vaccine uptake by insurance status were present in the FQHCs studied here, despite the fact that HPV vaccines are available to many patients regardless of ability to pay.Cervical cancer is a significant public health challenge in the United States. Approximately 12 300 women were expected to be diagnosed with cervical cancer in 2013, and 4030 were expected to die from the disease.1 The burden of cervical cancer disproportionately affects minority, low-income, and uninsured populations.2–4 The primary risk factor for virtually all cervical cancer is infection with certain types of human papillomavirus (HPV). Effective vaccines have been developed against HPV-16 and HPV-18, which alone are responsible for approximately 70% of cervical cancer cases.5–7 These vaccines hold great potential for reducing disparities in cervical cancer morbidity and mortality, if utilization can be encouraged in populations most at risk for cervical cancer.Federally Qualified Health Centers (FQHCs) serve the primary health care needs of more than 20 million patients in the United States, many of whom are low income, minorities or uninsured,8 and are thus an ideal setting in which to study the utilization of HPV vaccination among populations at highest risk for cervical cancer.9 However, few investigators have directly examined HPV vaccination rates in such settings,9–11 in part because of a lack of readily available data. Consequently, factors affecting HPV vaccine uptake in FQHCs are not well understood. In particular, the role of insurance coverage remains unclear.To date, studies of HPV vaccination rates in FQHCs have modeled insurance as a static variable, determined at a single visit or at the time services were rendered.9–11 This approach might be unsuitable when considering the association between insurance and HPV vaccine series completion, which requires multiple visits over several months,12 and may not accurately reflect the experience of FQHC patients whose coverage can change frequently affecting health care utilization.13–16 Furthermore, defining insurance status from a single visit prevents consideration of insurance duration or coverage continuity as potential factors influencing vaccine uptake. Among Medicaid enrolled patients, who constitute almost 40% of FQHC patients nationally,8 duration of insurance enrollment has been associated with HPV vaccine initiation, with longer enrollment being a predictor for initiating the vaccine series.17,18 Other researchers have demonstrated that, compared with being uninsured or sporadically insured, having continuous insurance coverage is positively associated with the receipt of preventive services in FQHCs, despite the fact that patients can receive care regardless of insurance coverage in these settings.16,19,20Existing studies of HPV vaccination in FQHCs have also been limited to patients younger than 19 years,9–11 precluding examination of insurance effects across the full age range for which the vaccine is recommended (9–26 years).12 In FQHC settings, the role insurance plays in vaccine uptake likely differs with age, as HPV vaccine is free for eligible children and adolescents younger than 19 years through the federal Vaccine for Children (VFC) program,21 but no similar program exists for patients aged 19 to 26 years. A better understanding of how insurance coverage and other factors affect uptake among female FQHC patients aged 19 to 26 years is needed to allow design of future interventions to reduce cervical cancer disparities in underserved populations.We leveraged electronic health record (EHR) data from a network of FQHCs to examine the association between insurance continuity and HPV vaccination in a large cohort of female patients (9–26 years of age) who accessed care between 2008 and 2010. We hypothesized that HPV vaccine uptake in our study population would be affected by insurance continuity, with lower rates of vaccine series initiation and completion among uninsured and discontinuously insured patients, compared with the continuously insured. We also hypothesized that insurance-related disparities would be most pronounced among women older than 18 years, who are ineligible for VFC. Our study helps fill a gap in published research by assessing the uptake of HPV vaccine in FQHC patients, including those older than 18 years, and applying EHRs to gather objective longitudinal data on insurance coverage and HPV vaccination rates in this population.     

Integrating Public Health and Personal Care in a Reformed US Health Care System

Compared with other developed countries, the United States has an inefficient and expensive health care system with poor outcomes and many citizens who are denied access.Inefficiency is increased by the lack of an integrated system that could promote an optimal mix of personal medical care and population health measures. We advocate a health trust system to provide core medical benefits to every American, while improving efficiency and reducing redundancy.The major innovation of this plan would be to incorporate existing private health insurance plans in a national system that rebalances health care spending between personal and population health services and directs spending to investments with the greatest long-run returns.THE UNITED STATES HAS THE most technologically intensive medical practice in the world.¹ It also spends more than any other nation on medical care,² but health outcomes in the United States are inferior to those in most other developed nations.^3–7 This inefficiency—spending more with poorer results—stems partly from failure to provide effective access to medical care to a substantial share of the population.^8,9 Lack of access leads to wider disparities in health in the United States than are experienced by the populations of other developed nations. The fragmented delivery system also leads to cost shifting (insurers'' attempts to transfer costs to other payers), administrative waste, and an imbalance between spending on medical care and spending on population health initiatives.There is general agreement that the US health care system should be more efficient as well as more equitable.^10,11 Most comprehensive proposals for reforming the system recognize the need for universal coverage that is independent of employment status, disability status, or age, although some would continue to rely on employers to collect health insurance payments.¹² Although universal insurance is important, it is not the only urgent issue. A reformed system should integrate personal preventive and therapeutic care with public health and should include population-wide health initiatives. Coordinating personal medical care with population health will require a more structured system than has ever existed in the United States.We argue that a reformed health care system not only should provide health insurance coverage for all but should also be organized and funded to take advantage of new knowledge about medical and nonmedical determinants of health. This health trust system (HTS) would (1) assess the cost of health insurance equitably, (2) promote efficiency by reducing fragmentation and relying on competitive markets, (3) allow coordination of spending on population health and personal medical care, (4) accommodate heterogeneous preferences, and (5) build on existing American health insurance and provider institutions, informed by international experience.     

Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults

Objectives. We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.Methods. We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992–2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.Results. The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.Conclusions. Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.Implemented in 1965, Medicaid was designed as publicly funded health insurance coverage for indigent US citizens and legal permanent residents. The program is jointly funded by the state and federal governments, and states are mandated to provide coverage for children younger than 6 years whose family incomes fall below 133%, children between ages 6 and 17 years whose family incomes fall below 100%, and pregnant women whose incomes fall below 133% of the federal poverty level, as defined by the US Department of Health and Human Services1; individuals who are aged, blind, or disabled and who are eligible for Supplemental Security Income; and low-income Medicare beneficiaries. This program has provided health insurance access to a significant number of previously uninsured low-income Americans and continues to be the only route to health care coverage for many people.Nationwide, Medicaid coverage has been found to be associated with several positive outcomes. Medicaid recipients have greater access to medical treatment than uninsured individuals and, therefore, fewer emergency department visits.2–6 Medicaid enrollees have better overall health and lower mortality rates over time than uninsured persons, likely because they have increased access to treatment.7–10 As a result, their medical care is significantly less costly to society, because health problems are more likely to be addressed before the onset of complications and adverse outcomes.11Although the implementation of the Medicaid program has been a largely successful attempt to provide medical insurance, a significant number of low-income adults remain uninsured, mainly because childless adults without qualifying disabilities are ineligible.12–14 In response to this disparity, some states have developed programs to broaden eligibility criteria through a Section 1115 waiver. Massachusetts was among the first states to implement such an initiative, establishing the MassHealth program in July 1997. Among other provisions, the program extended Medicaid eligibility to families and childless adults whose incomes fell below 200% and 133% of the federal poverty level, respectively. MassHealth was jointly funded by the federal and state governments, with Massachusetts paying for roughly 46% of the program.15,16Outcome evaluations of the MassHealth program demonstrated it to be remarkably successful, with significant declines in uninsured rates, particularly among childless adults who would otherwise be ineligible for Medicaid coverage.17,18 Research by Long et al. found that the MassHealth program resulted in a 33% decrease in the rate of uninsured Massachusetts residents.19 Furthermore, Quigley et al. reported that the MassHealth program covers nearly 1 in 6 Massachusetts residents.15 Consequently, it is estimated that only 6% of adults and 3% of children in Massachusetts remained uninsured after implementation of the program.Although evaluations of MassHealth have provided strong support for the program, some evidence suggests that certain marginalized populations are less affected by Medicaid expansion policies than others.16,20 Despite meeting the income eligibility criteria, many people living in poverty remain uninsured because they don''t know they are eligible, they don''t know how to obtain coverage, or they lack any form of identification.21,22 Homeless adults are disproportionately affected by lack of insurance and are reportedly difficult to enroll in public insurance programs.23,24 Although Massachusetts developed several approaches for targeting this hard-to-reach population, evidence suggests that the effort to enroll homeless adults and keep them enrolled faces many logistical barriers.16These challenges are even greater among homeless individuals with substance use disorders. These disorders are common among homeless persons, with prevalence estimates of 40% to 60%.25,26 These individuals generally have significantly greater health care needs, for treatment of, for example, psychiatric disorders, HIV and other sexually transmitted infections, hepatitis, liver disease, lung disease, and wound and skin infections.27–30 The premature mortality rate is significantly higher for homeless individuals than for the general population,27,31 and homeless people with substance use disorders are even more disproportionately affected.31,32 Finally, substance abuse is among the strongest predictors of returning to homelessness among formerly homeless individuals.33–36 Therefore, homeless adults'' lack of the Medicaid coverage necessary to obtain treatment is a significant public health concern.Assessing the impact of MassHealth is especially important in the context of national policy initiatives. Currently, many low-income childless adults qualify for Medicaid benefits because of a physical or mental health disability, but substance abuse is not among the conditions that confer eligibility, so many substance-abusing homeless adults who do not have children are ineligible for Medicaid coverage. However, a major provision of the Affordable Care Act is that all individuals with incomes that fall at or below 133% of the federal poverty level will be eligible for Medicaid effective January 2014, irrespective of parental or disability status. Although a Supreme Court ruling in June 2012 rejected a mandate for states to expand coverage,37 it is still expected that a significant portion of individuals with substance use disorders will benefit tremendously from the law''s expanded eligibility.To date, no large-scale quantitative evaluation has attempted to determine whether marginalized population groups, such as homeless substance-abusing adults, still have difficulty obtaining coverage under the Medicaid expansion.16,20–24 Data from state programs such as MassHealth are useful in assessing whether these groups will benefit from Medicaid expansion to the same extent as other population groups or may be in need of targeted interventions to improve their access. We examined administrative data on admissions to substance abuse treatment programs from 1992 to 2009 to assess the uptake of Medicaid coverage by substance-abusing homeless adults after the implementation of MassHealth in 1997. We assessed whether homeless adults entering substance use disorder treatment programs were less likely than housed adults to be covered by Medicaid. To rule out the potential impact of secular trends in national Medicaid coverage, we compared uptake of Medicaid coverage in adults entering substance abuse programs after 1997 in Massachusetts with rates in other states.     

Health insurance status, medical debt, and their impact on access to care in Arizona

Objectives. We examined the impact of health insurance status on medical debt among Arizona residents and the impact of both of these factors on access to care.Methods. We estimated logistic regression models for medical debt (problems paying and currently paying medical bills) and access to care (medical care and medications delayed or missed because of cost or lack of insurance).Results. Insured status did not predict medical debt after control for health status, income, age, and household characteristics. Insured status (adjusted odds ratio [AOR] = 0.32), problems paying medical bills (AOR = 4.96), and currently paying off medical bills (AOR = 3.04) were all independent predictors of delayed medical care, but only problems paying (AOR = 6.16) and currently paying (AOR = 3.68) medical bills predicted delayed medications. Inconsistent coverage, however, was a strong predictor of problems paying bills, and both of these factors led to delays in medical care and medications.Conclusions. At least in Arizona, health insurance does not protect individuals from medical debt, and medical debt and lack of insurance coverage both predict reduced access to care. These results may represent a troubling message for US health care in general.Financial hardship caused by out-of-pocket medical expenses is a large and growing problem in the United States. In 2007, it was estimated that 19% of the population had problems paying medical bills (up from 15% in 2003).¹ Another 2007 study estimated that 41% of the population aged 19 to 64 years had problems paying medical bills, had accrued medical debt, or both.^2,3 That estimate was up from 34% in 2005.Health insurance coverage should protect individuals from medical debt. However, in contrast with most insurance products, which indemnify losses stemming from low-probability and high-consequence events, health insurance plays the dual role of promoting actions to prevent such events and protecting against loss from them. Furthermore, in the United States health insurance rarely provides complete protection against financial loss caused by illness or injury. Rather, increasing portions of medical costs are paid directly by the insured in the form of copayments, deductibles, exclusions and limits on covered benefits, coinsurance provisions, and lifetime spending caps. In fact, a substantial portion of individuals both insured and uninsured, as well as individuals across a wide range of ages and income levels, have reported that paying medical bills is a problem.^1–6At least to some extent, medical debt is also more damaging than are other types of consumer debt because medical bills are often incurred through an illness or injury that limits one''s ability to work. Specifically, problems paying medical costs are associated with higher credit card debt,⁷ more calls from bill collectors,⁷ increased bankruptcy rates,^7–10 and diminished access to care.^{1,4–6,11,12}We took advantage of a large health-related data set to examine medical debt and its consequences in Arizona. Because substantial national attention has been devoted to reducing the ranks of the uninsured in an attempt to improve access to care,^13–16 we particularly focused on estimating the impact of health insurance status on the prevalence of debt and the impact of both of these factors on access to care.     

Universal Health Insurance and Health Care Access for Homeless Persons

Objectives. We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.Methods. We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.Results. Unmet health care needs were reported by 17% of participants. Compared with Toronto''s general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.Conclusions. Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.Homeless people are among the most marginalized groups in society, and large numbers of homeless individuals are found in the United States, Canada, and throughout the world.^1,2 Although the majority of homeless people are men, women and parents with children represent substantial segments of the homeless population.³ Homeless people suffer from many serious threats to their health, including an increased risk of all-cause mortality.⁴ Common medical conditions in this population include epilepsy, chronic obstructive pulmonary disease, hypertension, diabetes, and musculoskeletal disorders.⁵ Substance abuse, mental illness, and related comorbidities are also highly prevalent.⁵Despite high levels of morbidity and mortality, homeless people face numerous financial and nonfinancial barriers to obtaining needed health services.^6,7 A 1996 nationwide survey of homeless people across the United States found that 57% were uninsured, and lack of health insurance was associated with significantly lower odds of using ambulatory health care.⁷ Nonfinancial barriers have also been described. Competing priorities such as securing adequate food and shelter may lead to delays in seeking health care.⁸ Lack of transportation to health visits, long waiting times in clinics, and feelings of being stigmatized by health care professionals are also obstacles frequently reported by homeless people.^6,9 Lack of appropriate health care for homeless people may contribute to deterioration in health status, prolonged homelessness, and even death.^10,11Most studies of unmet needs for care among homeless individuals have been conducted in the United States.^6,7,12 Unmet needs for medical care in the past year were reported by 25% of respondents in a nationwide survey of homeless people in the United States and were somewhat more common among homeless families than among single homeless persons (27% vs 24%, respectively).^7,13 Studies conducted in various US urban centers have found even higher rates of unmet needs for care. Among homeless people living in urban encampments in Los Angeles, California, 41% felt there was a time in the past 6 months when they had needed to go to a doctor but did not.¹² A study of homeless women in Los Angeles County in 1997 found that 37% of participants had unmet needs for health care in the past 60 days.⁶ In a survey of low-income adults in Baltimore, Maryland, 57% of whom were homeless, 51% reported having difficulty accessing health care services.¹⁴ A recent study conducted in Birmingham, Alabama, found that the prevalence of unmet needs for care among homeless people rose from 32% in 1995 to 54% in 2005.¹⁵ This overall pattern suggests inadequacy of the US health care safety net for low-income and uninsured individuals.¹⁵Canada has a publicly funded system of universal health insurance that consists of single-payer plans administered by each province. All medically necessary physician services and hospital-based care are fully covered with no copayments. However, the extent to which such a system meets the needs of severely disadvantaged individuals has not been well defined.^16,17 Our objectives were to determine the prevalence of unmet needs for health care among homeless single men, single women, and women with dependent children within Canada''s universal health insurance system and to identify individual characteristics associated with having unmet needs.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

The Relationship Between Remittances and Health Care Provision in Mexico

Objectives. We examined whether remittances sent from the United States to Mexico were used to access health care in Mexico.Methods. Data were from a 2006 survey of 2 localities in the municipal city of Tepoztlán, Morelos, Mexico. We used logistic regression to determine whether household remittance expenditure on health care was associated with type of health insurance coverage.Results. Individuals who lacked insurance coverage or who were covered by the Seguro Popular program were significantly more likely to reside in households that spend remittances on health care than were individuals covered by an employer-based insurance program.Conclusions. Improving the coverage and quality of care within Mexico''s health care system will help ensure that remittances serve as a complement, and not a substitute, to formal access to care.Every year, Mexican migrants living in the United States send home billions of US dollars in the form of remittances, also known as “migradollars.” Since the 1980s, the flow of remittances has increased annually so that in 2006, Mexicans in the United States remitted 10 times the amount that was remitted in 1990, with an average annual growth rate of 15%.¹ According to the Central Bank of Mexico, remittances to Mexico during 2006 totaled $23.1 billion.² In 2007, the sum of remittances appears to have leveled off: a survey conducted for the Inter-American Development Bank estimated total remittances for 2007 to be $23.4 billion.³Existing evidence suggests that remittances are used largely to purchase basic necessities.^4–7 In this context, US remittances provide migrants and their families in Mexico access to goods and services that they could not otherwise afford, including food, housing, and consumer goods. Another possibility that has received less attention in the literature is that remittances are used to access health care.Mexico is marked by large inequities in health care access and consumption.⁸ The provision of health care is governed by a hybrid combination of employment-based formal insurance for salaried workers, publicly provided services for those excluded from formal insurance programs, and a much smaller percentage (2%) with private insurance coverage.⁹ According to the 2005 Mexican Conteo de Población y Vivienda (Count of Population and Housing), approximately 40% of the Mexican population had access to a formal insurance program.¹⁰The rest of the population falls outside of the purview of formal social insurance programs and includes those who are self-employed, nonsalaried, unemployed, and informal workers; the majority of which are poor and are served by the Secretaría de Salud (SSA; Mexican Ministry of Health).⁹ The uninsured largely access health care through out-of-pocket payments paid either to public clinics or to a large, mostly unregulated private sector that provides fee-for-service care.¹¹ Out-of-pocket payments represent the highest proportion of health care expenditure in Mexico.¹² In an effort to reduce out-of-pocket spending and promote more equitable resource distribution, a new program called Seguro Popular (Popular Health Insurance Program) was introduced in 2004 and continues to expanded across the country.⁸ The program''s aim is to increase financial protection of individuals outside the formal insurance programs by providing coverage for essential interventions (249 as of 2006) and selected catastrophic treatments.¹¹ The package of covered services will be expanded and updated annually. Currently, the program includes ambulatory care and hospitalization for basic specialties (e.g., internal medicine, general surgery, obstetrics and gynecology, pediatrics, geriatrics).⁸ As of September 2006, roughly 4 million families were enrolled in the program.¹¹Migrants living in the United States (i.e., international migrants) and their families in Mexico may be more reliant on out-of-pocket spending on health care, which may be funded by remittances. Because they are less likely to have salaried jobs within the formal economy in Mexico, they are less likely to have access to an employer-based formal health insurance program in Mexico.¹³ There is some existing evidence that remittances are used to purchase health services in Mexico, although estimates vary widely. One study based on a community survey in Oaxaca estimates that as little as 1% of remittances are spent on health care.¹⁴ Estimates from a national-based survey of migrant households put the number closer to 50%.¹⁵ Such variability in estimates is likely caused by differences in sampling frames and survey methodology (e.g., whether respondents were allowed to list multiple uses for remittances or only 1). One of the few existing studies that looks explicitly at the relationship between remittances and household expenditure on health care used data from the Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH; National Household Income and Expenditure Survey).¹⁶ The study found that households receiving remittances spend more money on primary care expenses than do those that do not receive remittances.¹⁶ Another study using the ENIGH data also found a similar effect and reported that households receiving remittances exhibit a 44% rise in the share of the household budget spent on health care.¹⁷ Data from the Encuesta Nacional a Hogares Rurales de Mexico (ENHRUM; Mexico National Rural Household Survey) found that rural households with international migrants spend more income on health than do either internal migrant households or households with no migrants.¹⁸The pattern between remittance receipt and health expenditure coupled with Mexico''s large uninsured population (estimated at over 50%) raises the possibility that remittances may be used as a compensatory mechanism to address gaps in health care provision among Mexican migrant families.^8,19 If remittances serve as a method for redressing gaps in health care coverage, we would expect to find differences in how remittances are used by health insurance status. We examined whether remittances sent from Mexican immigrants in the United States to relatives in Mexico are used to pay for health care in Mexico. We tested this possibility by examining patterns of household remittance expenditure by individual health insurance status.For all analyses we used data from a household census completed in the municipal city of Tepoztlán, Morelos, Mexico. The survey included an extensive module on US migration experience and remittance expenditure as well as health and health care, which allowed us to examine the associations between remittances, health insurance status, and health status at a level of detail that previously had not been possible.     

Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act

Objectives. We examined preventive care use by nonelderly adults (aged 18–64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.Methods. We used data from the 2005–2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.Results. There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.Conclusions. Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.The benefits of many preventive health care services are well-established.1 In the case of immunization, for instance, those who receive the recommended services are likely to avoid a variety of life-threatening diseases while promoting herd immunity and protecting individuals who are unable to be immunized.2 Those appropriately screened for cancer are likely to receive more timely diagnosis and treatment, which ultimately leads to better outcomes.3 Furthermore, early detection of heart disease, diabetes, and other chronic conditions can lead to the promotion of healthier lifestyles and better management of the diseases.4 Despite this evidence, many studies have shown the use of preventive services, including cholesterol checks, Papanicolaou (Pap) tests, mammograms, colon cancer screenings, and flu vaccines to be below recommended levels.5–9In recent years, the growing prevalence of obesity and chronic conditions and the evidence that modifiable behaviors are among the leading causes of death have led to a renewed emphasis on promoting health and wellness as opposed to treating disease.10,11 This emphasis on prevention was particularly evident in the national conversation leading up to the passage of the Affordable Care Act (ACA) in March 2010. Increasing access to preventive care was one motivation for expanding coverage to the uninsured, and was the explicit goal of an additional provision in the ACA requiring private insurers to cover recommended preventive services without any cost-sharing obligations to consumers. The effects of these ACA policies on preventive service use will depend on the extent to which preventive services are currently underused and whether expanding coverage will increase the receipt of these services.We examined the receipt of 8 preventive services by nonelderly adults in the years before the ACA (2005–2010), thus providing recent evidence on the extent of underuse of a variety of important services. Previous studies have found that lower rates of service use are generally associated with more limited education, low incomes, and a lack of insurance coverage12–14; we concentrated on the disparities in service use between the lower-income adults most likely to benefit from the ACA coverage expansion and their higher-income counterparts. Using a regression-based decomposition analysis, we identified the roles of insurance coverage, education, and other factors in explaining these income-related disparities. The results provide important insights on the potential of ACA efforts to increase the use of preventive care through coverage expansion as well as on the limitations of such efforts.Our conceptual framework relies on human capital models, which suggest that the demand for medical care is derived from the demand for health.15,16 According to such models, critical factors that are expected to affect the demand for health and medical care include age, health status, education, and rate of time preference. In some cases, the effects of these factors on demand for preventive care may be distinct from their effects on demand for treatment. In the case of age, for example, the demand for treatment, or curative care, is expected to increase with age as an individual’s health depreciates, whereas investment in preventive medical care is expected to decrease with age as the payoff period for avoiding future illness shortens.13,17 This reflects a more general distinction between investment and consumption considerations in the demand for preventive care, which is also relevant with respect to the role of health status. From a consumption perspective, those in poor health are more likely to use preventive services, but healthy individuals and those who are future-oriented are also more likely to invest in health and preventive care.18,19 Lastly, although the effect of education on the demand for health and health care is theoretically ambiguous,15 considerable empirical evidence finds a positive relationship between education and prevention activities.13,20–22Another critical consideration is the influence of insurance coverage on the demand for medical care. The direct effect of insurance is to lower the out-of-pocket cost of medical care and thus increase the demand for services. The RAND health insurance experiment provides the most rigorous evidence that this is the case,23 but many other studies provide empirical evidence that having health insurance is associated with increased utilization of medical care.24–27 The possibility exists, however, that because insurance coverage protects against the financial costs of adverse health events, it may reduce the incentive to invest in preventive care.17 Despite this potential for “ex ante moral hazard,” most empirical evidence finds that those with insurance coverage use more preventive care, including blood pressure screenings, mammograms, and other cancer screenings.28–30 Furthermore, those with more generous coverage and lower cost-sharing exhibit higher rates of preventive service use.31–33The ACA includes several components that expand coverage and reduce cost-sharing and thus have the potential to increase the receipt of recommended preventive care. The ACA includes an optional expansion of Medicaid for those with incomes less than 138% of the federal poverty level (FPL) and federal subsidies to purchase coverage in the new health insurance exchanges for those with incomes up to 400% of the FPL. The law also includes penalties for not having health insurance coverage and enhanced enrollment and outreach efforts. When fully implemented, the ACA is expected to significantly expand coverage, particularly among adults with incomes less than 400% of the FPL.34 Many of those becoming newly insured under the ACA are expected to experience improved access to recommended preventive services, given that these services will be included at no or low cost in exchange plans and under most Medicaid plans.In addition to the broader coverage expansions included in the ACA, the law includes new requirements for private health insurance coverage of a set preventive services rated “A” or “B” by the US Preventive Services Task Force.35 After September 2010, many private health plans were required to cover the specified services, and to do so at no cost to members. Although coverage for some of the ACA-mandated services is already relatively common, other services, such as diet and tobacco counseling, are likely to see expanded coverage under the law.36 Furthermore, with the notable exception of mammograms, few of the mandated services are currently required to be covered by private plans under state laws.37     

National and State-Specific Health Insurance Disparities for Adults in Same-Sex Relationships

Objectives. We examined national and state-specific disparities in health insurance coverage, specifically employer-sponsored insurance (ESI) coverage, for adults in same-sex relationships.Methods. We used data from the American Community Survey to identify adults (aged 25–64 years) in same-sex relationships (n = 31 947), married opposite-sex relationships (n = 3 060 711), and unmarried opposite-sex relationships (n = 259 147). We estimated multinomial logistic regression models and state-specific relative differences in ESI coverage with predictive margins.Results. Men and women in same-sex relationships were less likely to have ESI than were their married counterparts in opposite-sex relationships. We found ESI disparities among adults in same-sex relationships in every region, but we found the largest ESI gaps for men in the South and for women in the Midwest. ESI disparities were narrower in states that had extended legal same-sex marriage, civil unions, and broad domestic partnerships.Conclusions. Men and women in same-sex relationships experience disparities in health insurance coverage across the country, but residing in a state that recognizes legal same-sex marriage, civil unions, or broad domestic partnerships may improve access to ESI for same-sex spouses and domestic partners.There are approximately 646 000 same-sex couples in the United States according to the 2010 decennial census.1 Same-sex couples reside in every state, but each state has its own laws and regulations regarding the legal status of same-sex marriage. At the time of this writing, 16 states and the District of Columbia had recognized legal marriages for same-sex couples; an additional 3 states had extended civil unions or comprehensive domestic partnerships to same-sex couples; and the remaining states had banned same-sex marriage altogether through legislative action or amendments to their state constitutions.2 Differences in same-sex marriage laws can affect access to health insurance for same-sex couples or members of the lesbian, gay, bisexual, and transgender (LGBT) population. When states adopt same-sex marriage or civil unions that extend spousal rights and protections to same-sex couples, fully insured private employers regulated by state insurance laws are often required to treat married same-sex couples as married opposite-sex couples.The Employee Retirement Income Security Act of 1974 limits the reach of state insurance regulation. Although states maintain jurisdiction over fully insured health plans, employers that self-insure—or assume the risk of health claims out of their own assets—are regulated under the federal Employee Retirement Income Security Act, as health benefits are treated not as insurance but as an employee benefit similar to employer-provided pension plans.3,4 In 2010, more than half of all workers (57.5%) with employer-sponsored insurance (ESI) were covered by self-insured plans.5 Because so many workers are covered by self-insured plans, state-level marriage policies can have a limited effect. Buchmueller and Carpenter, using data from the 2001–2007 California Health Interview Surveys, found that insurance mandates that extended health care benefits to same-sex spouses in California had no statistically significant effect on dependent coverage for gay and bisexual men and only a small positive effect on lesbian and bisexual women.6The federal Defense of Marriage Act, passed in 1996, created additional barriers for LGBT workers interested in adding their spouses to their ESI plan, even when states acknowledged the legality of same-sex marriage. Section 3 of the Defense of Marriage Act (ruled unconstitutional by the US Supreme Court in 2013) defined marriage as “a legal union between one man and one woman as husband and wife” for federal purposes.7 The federal government does not tax employer contributions to an opposite-sex spouse’s health benefits, but under the Defense of Marriage Act, a same-sex partner’s health benefits were taxed as if the employer contribution was taxable income. LGBT employees paid, on average, $1069 in additional federal income taxes when they added their same-sex spouses to employer health plans.8 These barriers to ESI may have led LGBT persons to enroll in public programs or forgo health insurance and access to affordable health care.Data on the LGBT population have historically been limited to convenience and nonprobability samples of gay men and lesbians through health care providers and researchers focusing their research on LGBT health.9 Although federal surveys do not ascertain sexual orientation, data have been edited to identify same-sex couples and households. Three previous studies have used intrahousehold information from federal population surveys to compare the health insurance coverage of individuals in same-sex relationships with that of those in opposite-sex relationships.Heck et al. used the National Health Interview Survey to compare health insurance coverage and access to medical care of adults in same-sex relationships with that of married adults in opposite-sex relationships.10 They used multivariate logistic regression models for men and women and found women in same-sex relationships significantly less likely to have health insurance, to have seen a medical provider in the previous 12 months, and to have a usual source of care. Health insurance coverage, unmet medical needs, and having a usual source of care were not statistically different between men in same-sex relationships and married men in opposite-sex relationships. The authors believed the HIV epidemic motivated gay men to maintain a regular provider. Compared with the other studies using federal surveys, the National Health Interview Survey accommodates the smallest sample size (316 men and 298 women in same-sex relationships)—even after pooling data across a wide time frame (1997–2003).Ash and Badgett took advantage of larger samples in the Current Population Survey.11 Designed to measure labor force participation and unemployment, the Annual Social and Economic Supplement to the Current Population Survey requires respondents to report health insurance coverage during the previous 16 months for each person in the household. Pooled data between 1996 and 2003 still produced relatively small sample sizes (486 men and 478 women in same-sex relationships), but their study found that both men and women in same-sex couples were 2 to 3 times more likely to be uninsured than were married individuals in opposite-sex relationships.Buchmueller and Carpenter used a national sample of adults aged between 25 and 64 years in the Behavioral Risk Factor Surveillance System to compare health insurance and utilization of health services of same-sex couples with those of opposite-sex couples (both married and unmarried).12 Again, both men and women in same-sex relationships were significantly less likely to be insured. Married people in opposite-sex relationships had the highest rates and odds of insurance coverage, followed by men and women in same-sex relationships, and then by unmarried men and women in opposite-sex relationships. Although it provides the largest sample to date (2384 men and 2881 women in same-sex relationships), their study pooled data across a wide period (2000–2007) of decline in health insurance coverage, especially for people with ESI.13These 3 studies were restricted to national-level estimates and surveys with limited sample sizes. Our research builds on the previous work but extends the analysis to all states. To our knowledge, only 1 other study has estimated health insurance disparities for same-sex couples in a single state using the California Health Interview Study.14 Because of the variation in state policies and attitudes toward same-sex couples,15,16 we expected geographic patterns in health insurance. We took advantage of relatively large samples in the American Community Survey (ACS) to compare state-specific health insurance disparities, particularly in ESI coverage. Following recent studies examining the potential for same-sex marriage to improve the health of the LGBT population,17–20 we sought to add early evidence on the relationship between legal same-sex marriage and health insurance coverage.     

Impact of Health Insurance on Health Care Treatment and Cost in Vietnam: A Health Capability Approach to Financial Protection

We applied an alternative conceptual framework for analyzing health insurance and financial protection grounded in the health capability paradigm.Through an original survey of 706 households in Dai Dong, Vietnam, we examined the impact of Vietnamese health insurance schemes on inpatient and outpatient health care access, costs, and health outcomes using bivariate and multivariable regression analyses. Insured respondents had lower outpatient and inpatient treatment costs and longer hospital stays but fewer days of missed work or school than the uninsured.Insurance reform reduced household vulnerability to high health care costs through direct reduction of medical costs and indirect reduction of income lost to illness. However, from a normative perspective, out-of-pocket costs are still too high, and accessibility issues persist; a comprehensive insurance package and additional health system reforms are needed.Health insurance reform is of utmost concern for low-income countries that rely on out-of-pocket payments to finance health treatment, but many new policies have not been sufficiently assessed for their impact on the health and economic stability of households. A review of the World Bank impact evaluation database found that of 41 health-related impact evaluations as of April 2005, health reform and financing studies were lacking.1 Many studies focus on a particular change within a system, rather than changes affecting the entire system. For example, a Thai study2 investigated the impact of subsidizing the Thai health card scheme on insurance coverage and utilization. A Chinese study3 evaluated how changing hospital reimbursement from fee-for-service to prepayment affected health expenditure in China. Although these are important aspects of health insurance policy, they concern one change rather than system-wide reform. New insurance schemes constitute a major type of large-scale health care system reform, and require evaluation to determine whether they achieve their purpose. In this study, we employed a survey conducted in 2008 to assess the effects of reformed Vietnamese health insurance schemes on health care treatment and costs for households.Vietnam is a developing country that relies extensively on out-of-pocket payments for health care. In 2005, 5% of Vietnam’s gross domestic product was spent on health expenditure, and out-of-pocket payments accounted for 68% of health expenditure.4 Following the privatizing Doi Moi (“New Era”) economic reforms in the late 1980s, health care in Vietnam transitioned from a centralized system of free universal access to a user charge system at public health facilities and newly legalized private facilities. The pharmaceutical industry also became privatized. Out-of-pocket health payments as a proportion of total national health expenditure increased from 59% in 1989 to 80% in 1998, posing a substantial burden to ill households, particularly poor ones.5 In response to this problem, Vietnam instituted a health insurance system in 1993. At the time of its establishment, it consisted of compulsory health insurance (CHI) for employees of state institutions and of private businesses with more than 10 employees. A voluntary health insurance scheme was later added to cover the self-employed, informal-sector employees, dependents of CHI members, and employees at lower-level state institutions excluded by CHI.5–7In 2002, Vietnam reformed the insurance system. The government targeted the low-income population with Free Health Care Cards for the Poor, enrolling low-income individuals in a social health insurance scheme (a component of CHI). However, service provision was challenging because of limited funds, difficulty of the application process, and lack of public awareness of the scheme itself.8 The government addressed these problems through a decree called Decision 139, which required provincial governments to give free health care to disadvantaged populations.8Currently, CHI comprises 3 programs that in 2007 covered 41% of the population: (1) social health insurance for the formally employed (9%), retirees, dependents of military and police officers, and meritorious people (3%; which include war “heroes” and “veterans” and others with substantial contributions to the socialist revolution4); (2) Health Care Fund for the Poor (HCFP), which replaced Free Health Care Cards for the Poor (18%); and (3) free health care for children younger than 6 years (11%). CHI covers the costs of inpatient treatment at state hospitals and outpatient treatment at outpatient clinics or departments within state hospitals.6 It covers only inpatient drugs included on a Ministry of Health list. In most cases, it does not cover drugs for outpatient visits.4 The social health insurance and HCFP components of CHI are designed to offer the same benefits to their respective beneficiaries.6 Social health insurance is funded by a tax on payroll, pension, or salary not exceeding 3%, whereas HCFP receives three quarters of its funding from the central government and the rest from provincial government. Costs of health care for children younger than 6 are covered by the central government. Voluntary health insurance covered another 11% of the population in 2007 and is financed by individuals through private premiums, with costs dependent on financial capacity.6Several studies have assessed recent insurance reforms in Vietnam, revealing positive impacts. One study, which compared the out-of-pocket health payments for all health services of insured vs uninsured groups, found that health insurance decreased out-of-pocket expenses between 16% and 18%, with a more substantial decrease for lower-income residents.5 The social health insurance scheme increased health service utilization and reduced levels of self-medication.9 An evaluation of Vietnam’s HCFP, a program initiated in 2003, showed more mixed results.8 With insurance, poor households significantly increased utilization of inpatient treatments, with insured households 30% more likely to have inpatient treatment. However, the probability of utilizing outpatient services increased by only 16%, probably because of the limited insurance coverage of outpatient treatment. Moreover, poor households with insurance were still vulnerable to high health expenses. Nearly one third of HCFP beneficiaries were confronted with “catastrophic” out-of-pocket payments, defined as amounting to more than 10% of nonfood consumption. Another Vietnam study focused on the economic consequences of health shocks.10Most studies of Vietnam’s health insurance analyzed the Vietnam Living Standard Surveys (VLSS), a series of national household surveys in 1992 and 1993, 1997 and 1998, 2002, and 2004, but they did not include the 2006 wave. A more recent report by the World Bank included 2006 VLSS data, with conclusions similar to those of past studies. However, as the insurance system has undergone further changes since 2005, this analysis may not fully reflect the current insurance scheme and its impact on the Vietnamese population.We applied an alternative conceptual framework for analyzing health insurance and financial protection grounded in the health capability paradigm. As opposed to the narrow metrics of catastrophic and out-of-pocket expenditures, we broadly construed financial protection as that which reduces individual''s health and economic vulnerabilities and insecurities. We studied health insurance in terms of the effective rate of coverage and the extent to which that coverage results in better health care access, health outcomes, and financial security. Thus, health insurance was analyzed in the context of health and economic capabilities and security rather than the theory of the demand for health insurance or the narrow metrics of catastrophic, out-of-pocket payments.We present the results of a 2008 household survey that we designed and conducted from a capability perspective to study the impact of the current insurance scheme on households in Dai Dong, a rural commune of Hanoi, with particular emphasis on the vulnerable poor population. Because the survey covered the time period July 2007 to July 2008, our study addressed the consequences of recent changes, as well as implications for future reform. Rather than comparing households before and after insurance coverage, we compared households with and without insurance. In addition, we examined households that have insurance but do not use it, to better describe the reasons for and consequences of insurance underutilization. Furthermore, we focused on the subpopulation with at least 1 episode of illness. Unlike previous household surveys, in which the percentage of the sample population having an illness episode ranged from 35.1% to 62.4%,11 83.6% of our sampled households had at least 1 illness that warranted inpatient or outpatient treatment in the 12 months preceding the survey. Our study thus enabled us to more closely investigate the impact of insurance among ill individuals who need it most.Unlike previous studies that considered single insurance schemes such as HCFP,8 our study also compared the impact of HCFP with that of other types of insurance in Vietnam. Because studies have yet to adequately consider the impact of Vietnam’s insurance of children younger than 6 years, we included this as a separate insurance type in our study. In addition, whereas previous studies have included poor populations, we extended the frame to also include “near-poor” households. This is because policy discussions have been under way to possibly cover the “near-poor” population under HCFP.6 Our study evaluated the impact of health treatment costs on this particular group to better guide future policy.Our study was guided by a health capability conception of health insurance. According to this theoretical perspective, besides economic reasons, there are also moral and ethical claims for providing universal health insurance, and an effective insurance system must be driven by 2 foundational principles.12 The first is to ensure people’s ability for health functioning. That is, an individual must be able to obtain health care when necessary, and thereby achieve positive health outcomes. We investigated health care accessibility and health outcomes by gathering data on use of different public and private health facilities, health outcomes after treatment, and missed days of school and work through illness.The second goal is for insurance to enhance people’s security by decreasing their vulnerability to the detrimental economic effects of illness and health care costs. When faced with the high costs of health treatment, households are forced to pursue coping strategies such as borrowing and reducing food consumption, which create or exacerbate financial and health problems. An effective insurance system should reduce health costs and prevent their harmful consequences. To fully illuminate the effects of these costs on well-being, we examined all health treatment and treatment-associated costs among insured and uninsured populations. Both principles are part of an alternative framework for analyzing health insurance and financial protection.13a     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

Health Literacy: A Pathway to Better Oral Health

Objectives. We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient–dentist communication and dental care patterns.Methods. We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009–2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799).Results. Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient–dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01).Conclusions. Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient–dentist communication on oral health status. Improved patient–dentist communication is needed as an initial step in improving the population’s oral health.Oral health status is inexorably linked with general health,1 as evidenced by the association between poor oral health and chronic diseases, such as diabetes,2 cardiovascular disease,3 and respiratory disease.4 Among US adults, the burden of oral disease falls heaviest on vulnerable population groups,5–7 particularly those living in rural areas.8 Although improving oral health is named as one of the top 5 health priorities in Rural Healthy People 2010,9 little progress has been made in establishing public health programs to address this priority area. To achieve the goal of improved oral health, it is essential to study the risk factors associated with the oral health status of individuals residing in rural areas and to understand the relationships among these risk factors.The association between low dental care utilization and poor oral health outcomes has been proposed as a partial explanation for urban–rural disparities in oral health status.10–13 The rate of dental care utilization is lower among US rural than general populations, and dental visits tend to be problem—rather than prevention—oriented.14–17 Low levels of financial security and a lack of dental providers in rural areas are cited as major reasons for the low utilization rates in rural populations.12,18,19 However, evidence that individuals with dental insurance benefits choose to forgo regular preventive dental care suggests the presence of additional determinants in dental care utilization.20Previous research showed that communication between dentists and their patients plays an important role in the use of dental services.21–24 Effective patient–dentist communication increases utilization of dental services by lessening dental anxiety and, as a result, increasing patient perceptions of provider competence.25 Conversely, deficient communication skills, on either side of the patient–provider equation, are likely to increase dental anxiety and overall dissatisfaction with care.Health literacy deficits can interfere with effective patient–dentist communication. Individuals with low health literacy skills often have difficulty describing dental problems to their dentist and understanding dental conditions described by the dentist.26 Rozier et al. surveyed about 2000 dentists in the United States regarding the use of the 5 domains of communication techniques: interpersonal communication, teach-back method, patient-friendly materials and aids, assistance, and patient-friendly practice.27 Findings revealed low routine use by dentists of each communication technique, including those thought to be most effective with patients who demonstrate low health literacy.The association between low health literacy and poor health outcomes is well established.28–30 However, in the context of oral health, the literature offers few studies identifying the relationship between health literacy and oral health outcomes. It has been suggested that those with low health literacy are at highest risk for oral diseases and problems31 and that low health literacy may be associated with barriers to accessing care and with oral health behaviors such as seeking preventive care.32 Furthermore, rural residents have lower health literacy skills than urban residents.33 However, how health literacy is related to oral health status among rural populations remains an unanswered question.Frequently acknowledged risk factors for poor oral health include gender (male), race (Black), educational attainment (low), financial status (low), and access to dental care (none). We controlled for these factors in an examination of the effects of health literacy, patient–dentist communication, and dental care patterns on self-rated oral health status. In addition, we tested mediational pathways between health literacy and self-rated oral health. We hypothesized that greater health literacy would be associated with better patient–dentist communication, and in turn, that better patient–dentist communication would be associated with an increased likelihood of seeking regular dental care, ultimately leading to better self-rated oral health.     

Health Care Reform and Young Adults' Access to Sexual Health Care: An Exploration of Potential Confidentiality Implications of the Affordable Care Act

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent’s private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences.Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues.Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.ON MARCH 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, effecting the most significant change to the US health care system since the creation of the Medicare and Medicaid programs in 1965.1 All components of the health sector are affected: the legislation includes expansions of public coverage, new subsidies for private coverage, health insurance exchanges, insurance coverage requirements and mandates, and strategies to increase the efficiency of health care delivery and rein in health care costs. Such sweeping reforms bring a host of intended changes and potential unforeseen ramifications. One provision of the ACA expands access to dependent coverage for young adults on their parent’s health insurance up to age 26 years, regardless of marital, employment, or educational status, effective September 2010. Previously, the maximum age varied by state, with eligibility for dependent coverage often linked to factors such as educational enrollment status. The government Web site describes the intended benefits of this provision: “By allowing children to stay on their parent''s plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.”2Young adults aged 19 to 26 years have the highest uninsured rate of any age group in the country; 30% were without coverage in 2009.3 The high rate reflects many contributing factors. Young adults are more likely than other working-aged adults to be unemployed; if working, they are more likely to be newly employed, employed in entry-level jobs, and working in part-time positions without access to employer coverage. Furthermore, most young adults do not meet the traditional categorical eligibility requirements for the Medicaid program—the parent of a child younger than 19 years or an aged or disabled individual—and so young adults, even those with very low incomes, seldom qualify for public coverage. The subsequent low levels of insurance result in limited access to care and high levels of unmet need for care.4By expanding access to health insurance coverage, the ACA addresses two Healthy People 2020 goals5: attaining a higher proportion of individuals with insurance and reducing the proportion of individuals who are unable to obtain or who delay obtaining necessary medical care. This provision of the ACA has already shown significant success in expanding health insurance coverage for young adults. The percentage of young people with health insurance increased by 3.8 points from the first quarter of 2010 to the first quarter of 2011, far outstripping gains in other age groups.6 However, the reliance on expanding dependent coverage to address the high levels of uninsured young adults contains the potential for unintended consequences, because concerns about confidentiality could disrupt access to care.     

Health Care Coverage and the Health Care Industry

Objectives. We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category.Methods. We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype.Results. Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI] = 2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI = 3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR] = 1.5; 95% CI = 1.0, 2.4).Conclusions. Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern.For complex socioeconomic reasons, private health insurance, typically provided by an employer, is “the dominant mechanism for paying for health services” in the United States.^1(p79) According to the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, analyses of data from the Current Population Survey (CPS) show that, in 2006, 54% of the US civilian, noninstitutionalized population had employer-sponsored health insurance; 5% had private, nongroup health insurance; and 26% had public health insurance coverage. Approximately 46 million US residents (16% of the population) are currently uninsured.² Numerous studies have shown that, relative to people with health insurance, uninsured people receive less preventive care, are diagnosed at more advanced disease stages, and, once diagnosed, tend to receive less therapeutic care and have higher mortality rates.^3–8Although national uninsurance trends are well-documented, the rate of uninsurance within the health care workforce has received scant attention. Given that health care employment rates are increasing at a more rapid pace than overall employment rates, this lack of attention is especially worrisome. According to the Bureau of Labor Statistics, nearly half of the 30 occupations in which employment opportunities are growing fastest are health care occupations. For example, whereas the Bureau of Labor Statistics projects that overall employment will increase about 10% from 2006 to 2016, employment opportunities for personal and home care aides are projected to increase nearly 51%, and opportunities for physical therapist assistants are expected to increase by a third. The Bureau of Labor Statistics also projects that, by 2016, new job opportunities for registered nurses will increase by approximately 24% (approximately 587 000 new jobs).⁹Although the overall employment outlook for health care workers is promising, what is less clear is to what degree employment in health care is associated with health insurance coverage. A 2001 General Accounting Office report suggested that one fourth of nursing home aides and one third of home health care aides were uninsured.¹⁰ The Kaiser Family Foundation reported that the uninsured rate among workers in the health and social services industry was 23% in 2007.¹¹ On the basis of a review of the literature in the health and human services occupations, Ebenstein concluded that the health insurance plans offered to direct care workers in the developmental disabilities field are “inferior … with less coverage and more out-of-pocket expenses” and that fewer direct care workers “are able to afford health coverage even if they are eligible.”^12(p132)Taking a more comprehensive look at the US health care workforce, Himmelstein and Woolhandler¹³ used 1991 CPS data to estimate uninsurance rates among physicians and other health care personnel. They reported that, overall, 9% of health care workers were uninsured, along with more than 20% of nursing home workers. Examining CPS data from 1988 to 1998, Case et al. found that uninsurance rates among all health care workers rose from 8% to 12%, that rates increased more for health care workers than for workers in other industries, and that rates differed according to occupation and place of employment.¹⁴ For example, occupation-specific uninsurance rates were 23.8% among health aides, 14.5% among licensed practical nurses, and 5% among registered nurses, whereas place-specific rates were 20% among nursing home workers, 8.7% among medical office workers, and 8.2% among hospital workers.¹⁵In their studies, Himmelstein and Woolhandler¹³ and Case et al.¹⁴ used national-level data to estimate uninsurance trends among health care workers. However, these trends were not adjusted for health care workers'' social, demographic, or economic characteristics, which would have helped explain variation across categories or over time. Moreover, with the growth of the health care workforce, estimates from these older studies probably do not reflect the current situation. As a result, the picture of uninsurance as it pertains to the health care workforce lacks the precision and currentness necessary for sound policy decisions. In an effort to expand knowledge in this area, produce more up-to-date estimates, and provide support for possible policy decisions, we used data from the National Health Interview Survey (NHIS) to examine uninsurance among workers in the health care industry.