COBRA ARRA Subsidies: Was the Carrot Enticing Enough?

Objective

To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008–2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions.

Study Design/Data Collection

Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate).

Principal Findings

Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending.

Conclusion

Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.     

Differences in income-related inequality and horizontal inequity in ambulatory care use between rural and non-rural areas: using the 1998-2001 U.S. National Health Interview Survey data

Background

To better understand income-related inequalities in health care use, it is imperative to identify sources of inequalities and assess the extent to which health care use is still related to income after differences in need across the income distribution are accounted for. Little is known regarding rural-urban differences in income-related inequalities and subgroup variation in horizontal inequities in health care use. This study decomposes income-related inequalities in ambulatory care use into contributions of need and non-need factors and compares horizontal inequities of subgroups in rural and non-rural areas.

Methods

This analysis used non-elderly adult samples from the 1998 to 2001 U.S. National Health Interview Survey data. The area of residence was categorized as rural for non-Metropolitan Statistical Area (MSA) and non-rural for MSA. Concentration indices of ambulatory care use were used to gauge income-related inequalities and decomposed into contributing factors. Horizontal inequities were measured using two methods and the results were compared.

Results

Ambulatory care use was disproportionately concentrated in the poor before need adjustment. However, the results of decomposition and horizontal inequity analyses indicate that the pro-poor concentration of health care use was due to greater health care need in low-income groups. Adjusting for need, ambulatory care use was distributed favoring the better-off, to a larger degree in non-rural areas. Health-related variables were the major contributors to income-related inequalities. Non-need factors, including socioeconomic factors, health insurance, and usual source of care, also contributed to income-related inequalities. There were variation in determinants' contributions to income-related inequalities between rural and non-rural populations and subgroup differences in horizontal inequities. Horizontal inequities were greater within non-whites, high school graduates, individuals with private health insurance, and those without a usual source of care with some geographic variation.

Conclusions

Our analysis shows that seemingly pro-poor income-related inequalities in ambulatory care use were largely due to greater health care need among low-income groups. The results demonstrate different contributions of determinants to income-related inequalities and variation in horizontal inequities by subgroup and locale. The findings of this study should help identify targets for policy intervention for each rural and non-rural area.

     

Using community wealth ranking to identify the poor for subsidies: a case study of community‐based health insurance in Nouna,Burkina Faso

Access to health‐care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community‐based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low‐income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.     

Health insurance enrolment in the Upper West Region of Ghana: Does food security matter?

Toward achieving universal health coverage, Ghana's national health insurance has been acclaimed as a pro‐poor scheme, yet been criticized for leaving the poor behind. Arising from this is how poverty has been operationalized and how poor people are targeted for enrolment into the scheme. We examine the role of food insecurity (not currently considered) as a multidimensional vulnerability concept on enrolment into Ghana's health insurance using binary logistics regression on cross‐sectional survey of household heads (n = 1438) in the Upper West Region of Ghana. Our analyses show that heads of severely food‐insecure households were significantly less likely to enroll in national health insurance scheme (NHIS) relative to households who reported being food‐secure (OR = 0.36, P < .05). We also found education, occupation, and religion as significant predictors of health insurance enrolment. Based on our findings, it is crucial to incorporate food security status in the identification of vulnerable people for free enrolment in Ghana's health insurance.     

The Impact of Community‐Based Health Insurance on Utilization and Out‐of‐Pocket Expenditures in Lao People's Democratic Republic

Community‐based health insurance in Lao People's Democratic Republic targets the informal workforce. Estimates of the program's impact on utilization and out‐of‐pocket expenditures (OOPs) were obtained using a case‐comparison study of 3000 households (14 804 individuals) in urban and semi‐urban areas. We used propensity score matching to control for bias on observables and to account for heterogeneity. We check the sensitivity of the results using a weighted regression combined with propensity score matching, which leads to doubly robust treatment effect estimates. The results are robust across the two approaches and show that the insured have significantly higher utilization, lower OOPs and lower incidence of catastrophic expenditures, and are less likely to employ coping mechanisms. However, coverage of the scheme is extremely low, indicating negligible population level impact. Furthermore, the results show that the scheme provides greater protection to the better off than to the poor: the poor are less likely to enrol, and among the poor who are enrolled, there has been no significant impact on utilization of outpatient services, total OOPs or catastrophic expenditures. We discuss the policy implications in the context of the international debate regarding the prospects for the role of community‐based health insurance in national financing strategies. Copyright © 2013 John Wiley & Sons, Ltd.     

Income‐related health inequalities in working age men and women in Australia and New Zealand

Objective : To examine income‐related inequalities in health in working age men and women in Australia and New Zealand. Methods : We used data from two longitudinal surveys, Wave 8 (2008) of the Household Income and Labour Dynamics in Australia (HILDA) Survey and Wave 7 (2008/2009) of the New Zealand Survey of Family Income and Employment (SoFIE). We compared concentration indices (a measure of income‐related health inequality) that examined the distribution of general and mental health‐related quality of life scores (from the SF‐36) across income in working age (20–65 year old) men and women. Decomposition analyses of the concentration indices were done to identify the relative contribution of various determinants to the income‐related health inequality. Results : General health (GH) scores generally decline with age, and mental health (MH) scores increase with age, in both surveys. Income‐related health inequalities were present in both the HILDA and SoFIE samples, with better health in high income groups. Decomposition analyses found that income, area deprivation and being inactive in the labour force were major contributors to income‐related health inequality, in both surveys, and for both health outcomes. Conclusions and implications : Despite some baseline differences in income‐related health inequalities using Australian and New Zealand surveys, we found similar modifiable determinants, which could be targeted to improve health inequalities in both countries.     

Encouraging Health Insurance for the Informal Sector: A Cluster Randomized Experiment in Vietnam

Subsidized voluntary enrollment in government‐run health insurance schemes is often proposed as a way of increasing coverage among informal sector workers and their families. We report the results of a cluster randomized experiment, in which 3000 households in 20 communes in Vietnam were randomly assigned at baseline to a control group or one of three treatments: an information leaflet about Vietnam's government‐run scheme and the benefits of health insurance, a voucher entitling eligible household members to 25% off their annual premium, and both. At baseline, the four groups had similar enrollment rates (4%) and were balanced on plausible enrollment determinants. The interventions all had small and insignificant effects (around 1 percentage point or ppt). Among those reporting sickness in the 12 months prior to the baseline survey the subsidy‐only intervention raised enrollment by 3.5 ppts (p = 0.08) while the combined intervention raised enrollment by 4.5 ppts (p = 0.02); however, the differences in the effect sizes between the sick and non‐sick were just shy of being significant. Our results suggest that information campaigns and subsidies may have limited effects on voluntary health insurance enrollment in Vietnam and that such interventions might exacerbate adverse selection. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.     

The Impact of the Eligibility Threshold of a French Means‐Tested Health Insurance Programme on Doctor Visits: A Regression Discontinuity Analysis

This paper assesses the impact of eligibility for a free means‐tested complementary health insurance plan, called Couverture Maladie Universelle Complémentaire (CMUC), on doctor visits. We use information on the selection rule to qualify for the plan to identify the effect of eligibility and adopt a regression discontinuity approach. Our sample consists of low‐income individuals enrolled in the Health Insurance Fund and recipients of social benefits from the Family Allowance Fund of an urban area in Northern France. Our findings do not show significant impacts of the CMUC threshold on the number of doctor visits within the full sample. Among the subsample of adults under 30 years old, however, eligible individuals are more likely to see a specialist and have, on average, significantly more specialist visits than non‐eligible individuals. This specific impact of the CMUC cut‐off point among young adults may be explained by the fact that young adults are less likely to be covered by a complementary health insurance plan when they are not recipients of the CMUC plan. © 2017 The Authors. Health Economics Published by John Wiley & Sons, Ltd.     

Government subsidies for dental care in Australia

OBJECTIVES: To evaluate the impact of recent changes in public subsidies for oral health care in Australia, and to propose more effective and equitable uses of Commonwealth Government subsidies. METHODS: Review of literature and Australian Research Centre for Population Oral Health information. RESULTS: Commonwealth subsidies for oral health care services in Australia have been moved from public dental services to private dental health insurance. This has resulted in a redistribution of funds from people on low incomes with poor oral health, to people on middle to high incomes with relatively better oral health. CONCLUSIONS: Public funding for dental care in Australia favours the financially and orally better off at the expense of disadvantaged and orally unhealthy Australians. Current approaches to public funding for oral health services in Australia are unlikely to result in a substantial improvement in oral health. IMPLICATIONS: Maximum gains in oral health are likely to be achieved by a reorientation of Commonwealth subsidies towards preventive and basic treatment services. This reorientation needs to occur within a primary health care framework. Whereas the Commonwealth plays a national leadership role in the provision of general health services, this is not apparent in relation to oral health. This lack of leadership leaves many vulnerable Australians without basic preventive services and at high risk of losing teeth that might otherwise have been preserved. Channelling the funding now used to subsidise private dental services for the well off and dentally healthy to community-wide and targeted preventive services for vulnerable and low-income Australians would have a larger impact on oral health and represent a more equitable use of these funds.     

Geographical inequalities in healthcare utilisation and the contribution of compositional factors: A multilevel analysis of 497 districts in Indonesia

Substantial inequalities in healthcare utilisation are reported in Indonesia. To develop appropriate health policies and interventions, we need to better understand geographical patterns in inequalities and any contributing factors. This study investigates geographical inequalities in healthcare utilisation across 497 districts in Indonesia and whether compositional factors – wealth, education, health insurance – contribute to such inequalities. Using data from a nationally representative Basic Health Research survey, from 2013 (N = 694,625), we applied multilevel logistic regressions, adjusted for need, to estimate associations of compositional factors with outpatient and inpatient care utilisation and to assess variability at province and district levels. We observed large variation of healthcare utilisation at district level and smaller variations at province level. Cities had higher utilisation rates than rural districts. Compositional factors contributed only modestly to geographical inequalities in healthcare utilisation. The effect of compositional factors on individual healthcare utilisation was stronger in rural areas as compared to cities and other areas with higher population densities. Unexplained district variation was substantial, comparable to that associated with health insurance. In policies to tackle inequalities in healthcare utilisation, addressing geographical factors such as service availability and infrastructures may be as important as improving compositional factors like health insurance.     

The Rural–Urban Divide: Health Services Utilization Among Older Mexicans in Mexico

Context: Mexico. Purpose: Using the health care service utilization model as a framework, this paper will analyze the differences in health care service use among older Mexicans living in urban and rural areas in Mexico. Methods: The Mexican Health and Aging Survey (MHAS) data were used to test the applicability of Andersen's “model of health services” of predisposing (ie, age, sex, etc.), enabling (education, insurance coverage, etc.) and need factors (diabetes, hypertension, etc.) to predict ever being in the hospital and physician visits in the past year by place of residence (urban, rural, semi-rural). Findings: Results showed that older Mexicans living in the most rural areas (populations of 2,500 or fewer) were significantly less likely to have been hospitalized in the previous year and visited the physician less often (P < .0001) than their urban counterparts. The significant difference in hospitalization between rural and urban residing older Mexicans was largely accounted for by having health care coverage. Certain need factors such as diabetes, previous heart attack, hypertension, depression, and functional limitations predicted frequency of physician visits and hospitalization, but they did not explain variations between rural and urban older Mexicans. Conclusions: Not having insurance coverage was associated with a lower likelihood of spending an overnight visit in the hospital and visiting a physician for older Mexicans. This lower utilization may be due to barriers to access rather than better health.     

Sub-national assessment of inequality trends in neonatal and child mortality in Brazil

Objective  

Brazil's large socioeconomic inequalities together with the increase in neonatal mortality jeopardize the MDG-4 child mortality target by 2015. We measured inequality trends in neonatal and under five mortality across municipalities characterized by their socio-economic status in a period where major pro poor policies were implemented in Brazil to infer whether policies and interventions in newborn and child health have been successful in reaching the poor as well as the better off.     

The telehealth divide: disparities in searching public health information online

This article explores e government inequalities to searching Medicare and Medicaid information online. Telehealth, a branch of e government, can bring public health service and insurance information to the citizen. The Centers for Medicare and Medicaid Services website, among others, has critical information for potential beneficiaries and recipients of services. Using Pew survey data and multivariate regression analysis we find people in most need of Medicare and Medicaid information online (the elderly and poor) are accessing it, and people with years of online experience are strong proponents of online searches. Despite being less likely to have broadband services, individuals in rural areas were not found to be less likely to search for information online. In conclusion, some disparities are narrowing as the elderly and poor in need of access to public health insurance are searching for it online. However, people without Internet access and experience (perhaps the oldest and poorest) remain disadvantaged with respect to accessing critical information that can link them to needed health care services.     

Health insurance and the bamako initiative in Burundi: Value for money?

Despite its a priori attractiveness, health insurance schemes are rare in developing countries. A recent external review of the Bamako Initiative in Burundi considered the extent to which the ‘Carte d'Assurance Maladie’ (CAM) has the potential to improve the quality of, and access to, health services. Although utilization of the CAM was found to be low overall, most of those visiting the health centres were in possession of a card, leading the team to conclude that health service utilization for curative care is extremely low. Focus group discussion revealed that users perceive the quality of health services to be poor, and that frequent shortages of basic drugs and supplies create uncertainty as to whether the CAM will provide good value for money, the shortage of basic drugs, the lack of community participation in the management of health services, and the fact that very little of the revenue from sales of the CAM is spent on health service provision provide possible explanations for the weak uptake of health insurance. Closing the link between the payment for health services and the financing of those services would contribute to an improvement in the quality and the confidence of the population in government health services.     

Social inequalities in health‐related use of time in Australian adolescents

Objective: Young people's socioeconomic position and time use behaviours – including physical activity, sedentary behaviours, social engagement, sleep and cognitive activities – have been associated with health outcomes. This study aimed to describe how time use varies with household income in a representative sample of 9–16 year old Australians. Methods: A random sample of 2,071 9–16 year old Australian children provided household income data and four days’ use‐of‐time data. Average daily minutes spent in various types of activities were calculated. Kruskal‐Wallis and Mann Whitney U tests were used to compare time use across the income bands. Results: Higher income participants spent significantly more time playing sport (p<0.0001), including team sports (p=0.0005), and in cognitively demanding behaviours such as school routine (p<0.0001), doing homework (p<0.0001) and playing music (p=0.001) than their low‐income counterparts. Conversely, low‐income participants spent significantly more time watching television (p<0.001) and playing videogames (p<0.0002). There were no differences in sleep or social interaction. Screen time and school‐related activities were the major locations of differences. Conclusions: Time use differences in the areas of sport, school‐related and screen activities may be associated with various health and wellbeing outcomes, and thus be a source of health inequalities. Implications : Socioeconomic‐related time use behaviour differences could be used to develop specific interventions to address health inequalities via interventions addressing time use or income inequalities.     

Urban health in India: who is responsible?

Urban health has received relatively less focus compared with rural health in India, especially the health of the urban poor. Rapid urbanization in India has been accompanied by an increase in population in urban slums and shanty towns, which are also very inadequately covered by basic amenities, including health services. The paper presents existing and new evidence that shows that health inequities exist between the poor and the non‐poor in urban areas, even in better‐off states in India. The lack of evidence‐based policies that cut across sectors continues to be a main feature of the urban health scenario. Although the problems of urban health are more complex than those of rural health, the paper argues that it is possible to make a beginning fairly quickly by (i) collecting more evidence of health status and inequities in urban areas and (ii) correcting major inadequacies in infrastructure–both health and non‐health–without waiting for major policy overhauls. Copyright © 2014 John Wiley & Sons, Ltd.     

Healthcare financing in Yemen

Yemen is a low‐middle‐income country where more than half of the population live in rural areas and lack access to the most basic health care. At US$40 per capita, Yemen's annual total health expenditure (THE) is among the lowest worldwide. This study analyses the preconditions and options for implementing basic social health protection in Yemen. It reveals a four‐tiered healthcare system characterised by high geographic and financial access barriers mainly for the poor. Out‐of‐pocket payments constitute 55% of THE, and cost‐sharing exemption schemes are not well organised. Resource‐allocation practices are inequitable because about 30% of THE gets spent on treatment abroad for a small number of patients, mainly from better‐off families. Against the background of a lack of social health protection, a series of small‐scale and often informal solidarity schemes have developed, and a number of public and private companies have set up health benefit schemes for their employees. Employment‐based schemes usually provide reasonable health care at an average annual cost of YR44 000 (US$200) per employee. In contrast, civil servants contribute to a mandatory health‐insurance scheme without receiving any additional health benefits in return. A number of options for initiating a pathway towards a universal health‐insurance system are discussed. Copyright © 2012 John Wiley & Sons, Ltd.     

Psychosocial job adversity and health in Australia: analysis of data from the HILDA Survey

Objective: This study examines measures of psychosocial job quality developed from the Household Income and Labour Dynamics in Australia (HILDA) Survey, and reports on associations with physical and mental health. Methods: The study used seven waves of data from the HILDA Survey with 5,548 employed respondents. Longitudinal random‐intercept regression models assessed the association of time‐varying and between‐person measures of psychosocial job quality job adversity with physical and mental health. Results: Respondents’ specific experience of psychosocial job adversity, except marketability, was associated with increased risk of mental health problems, whereas the association between psychosocial job adversity and physical health was largely driven by differences between people. Conclusions and Implications: Moving into jobs with different psychosocial quality is associated with changes in mental health. In contrast, individuals with poor physical health show an increased propensity to work in poor‐quality jobs but it seems that changes in physical health are not as strongly tied to changes in job quality. Differences in the relationship between physical and mental health and psychosocial job quality have implications for the design of employment, health and social policy. The HILDA Survey is an important resource for policy development in Australia, and the availability of valid measures of psychosocial of job quality will enhance its use to better understand this important determinant and correlate of health.     

Healthy and Ready to Learn: Effects of a School‐Based Public Health Insurance Outreach Program for Kindergarten‐Aged Children

BACKGROUND

Rates of child insurance coverage have increased due to expansions in public programs, but many eligible children remain uninsured. Uninsured children are less likely to receive preventative care, which leads to poorer health and achievement in the long term. This study is an evaluation of a school‐based health insurance outreach initiative, “Healthy and Ready to Learn,” aiming to identify and enroll uninsured kindergarteners in areas of high economic need in 16 counties in North Carolina.

METHODS

Regression discontinuity design and difference‐in‐differences analyses were used to estimate the effect of the initiative on Medicaid and CHIP enrollment (primary outcome) and preventive care use (well‐child visits; secondary outcome). Focus groups and key‐informant interviews were conducted to assess best practices and identify barriers to outreach for child enrollment.

RESULTS

The initiative increased enrollment rates by 12.2% points and increased well‐child exam rates by 8.6% points in the RD models, but not differences‐in‐differences, and did not significantly increase well‐child visits.

CONCLUSIONS

Findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for low‐income parents.