The effect of new insurance coverage on the health status of low-income children in Santa Clara County

OBJECTIVE: To examine whether providing health insurance coverage to undocumented children affects the health of those children. DATA SOURCES/STUDY SETTING: The data come from a survey of 1235 parents of enrollees in the new insurance program ("Healthy Kids") in Santa Clara County, California. The survey was conducted from August 2003 to July 2004. STUDY DESIGN: Cross-sectional study using a group of children insured for one year as the study group (N=626) and a group of newly insured children as the comparison group (N=609). Regression analysis is used to adjust for differences in the groups according to a range of characteristics. DATA COLLECTION: Parents were interviewed by telephone in either English or Spanish (most responded in Spanish). The response rate was 89 percent. PRINCIPAL FINDINGS: The study group-who were children continuously insured by Healthy Kids for one year-were significantly less likely to be in fair/poor health and to have functional impairments than the comparison group of newly insured children (15.9 percent versus 28.5 percent and 4.5 percent versus 8.4 percent, respectively). Impacts were largest among children who enrolled for a specific medical reason (such as an illness or injury); indeed, the impact on functional limitations was evident only for this subgroup. The study group also had fewer missed school days than the comparison group, but the difference was significant only among children who did not enroll for a medical reason. CONCLUSIONS: Health insurance coverage of undocumented children in Santa Clara County was associated with significant improvements in children's health status. The size of this association could be overstated, since the comparison sample included some children who enrolled because of an illness or other temporary health problem that would have improved even without insurance coverage. However, even after limiting the study sample to children who did not enroll for a medical reason, a significant association remained between children's reported health and their health coverage. We thus cautiously conclude that Healthy Kids had a favorable impact on children's health.     

Measuring health insurance literacy in the Netherlands – First results of the HILM-NL questionnaire

BackgroundThere are several indications that citizens in the Netherlands struggle to make critical, well-considered decisions about which insurance policy best fits their needs and preferences. This can lead to citizens being sub-optimally insured, facing unexpected costs or suffering inadequate coverage. This study aims to examine how health insurance literacy (HIL) is distributed among citizens in the Netherlands; and to find out whether there are certain groups who have more difficulty choosing and using a health insurance policy.MethodsWe measured health insurance literacy using the HILM-NL questionnaire, the validated Dutch version of the original health insurance literacy measure (HILM). In February 2020, the HILM-NL was sent to 1,500 members of the Nivel Dutch Health Care Consumer Panel. The response rate was 54% (806).ResultsThere is a wide variation in HIL among citizens in the Netherlands. The average total HILM-NL score is 55.14 (on a range of 21–84). The level of education and the household net income are significantly related to HIL.ConclusionsCitizens who completed less education or earn a lower income are relatively more likely to have difficulty choosing a health insurance policy or using policy benefits to pay for health services once enrolled. It is important to support these vulnerable groups properly in their choice and use of a health insurance policy.     

Patterns of individual health insurance coverage, 1996-2000

Information about patterns of individual health insurance coverage is limited. Knowledge gaps include the extent to which individual insurance provides transitional versus long-term coverage, and participants' insurance status before and after being covered by an individual plan. In this study we use data from the 1996-2000 Survey of Income and Program Participation (SIPP) to examine how long the individually insured maintain their coverage; sources of coverage before and after enrolling in an individual health plan; and characteristics of those who rely on individual insurance coverage. Understanding the dynamics of this market will better inform federal and state insurance reform efforts.     

日本健康保险制度演变历程及启示

对日本医疗保险制度实现全民覆盖的历程以及现状进行分析,发现日本的健康保险制度演变有以下特点：以法律为依据,逐步实现全民覆盖;建立了健康保险基金的合理分担机制;不同保健制度覆盖人群的服务包逐渐趋同、补偿水平逐渐统一;不同保险方案之间建立了风险分担和资金转移机制;加强对供方的约束力,控制医药费用快速上涨。最后针对日本健康保险制度的演变特点给出我国医疗保险制度改革的政策建议：健全医疗保险的法律法规;调整筹资机制,逐步提高个人筹资责任;推进不同医保制度覆盖人群保障待遇的统筹和统一;建立不同健康保险制度之间的风险分担机制;积极探索支付方式改革,控制医药费用快速上涨。     

Building a Methodological Foundation for Impactful Urban Planetary Health Science

Anthropogenic environmental change will heavily impact cities, yet associated health risks will depend significantly on decisions made by urban leaders across a wide range of non-health sectors, including transport, energy, housing, basic urban services, and others. A subset of planetary health researchers focus on understanding the urban health impacts of global environmental change, and how these vary globally and within cities. Such researchers increasingly adopt collaborative transdisciplinary approaches to engage policy-makers, private citizens, and other actors in identifying and evaluating potential policy solutions that will reduce environmental impacts in ways that simultaneously promote health, equity, and/or local economies—in other words, maximising ‘co-benefits’. This report presents observations from a participatory workshop focused on challenges and opportunities for urban planetary health research. The workshop, held at the 16th International Conference on Urban Health (ICUH) in Xiamen, China, in November 2019, brought together 49 participants and covered topics related to collaboration, data, and research impact. It featured research projects funded by the Wellcome Trust’s Our Planet Our Health (OPOH) programme. This report aims to concisely summarise and disseminate participants’ collective contributions to current methodological practice in urban planetary health research.     

城镇职工医保适度缴费率确定的动态模型及“十三五”期间现有缴费率降低测算

目的:研究城镇职工医保适度缴费率确定的动态模型及对"十三五"期间降低现有缴费率进行测算。方法:构建数理模型对研究对象进行研究。结果:有8个参数共同决定城镇职工基本医疗保险适度缴费率。结论:"十三五"期间,如果保持现有统账结合的财务制度不变,城镇职工基本医疗保险可以把缴费率由8%降低为7.9%。如果取消城镇职工基本医疗保险个人账户,城镇职工基本医疗保险可以把缴费率由8%降低为7%。     

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

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

Does a mandatory telemedicine call prior to visiting a physician reduce costs or simply attract good risks?

This paper aims to estimate empirically the efficiency of a Swiss telemedicine service introduced in 2003. We used claims' data gathered by a major Swiss health insurer, over a period of 6 years and involving 160 000 insured adults. In Switzerland, health insurance is mandatory, but everyone has the option of choosing between a managed care plan and a fee‐for‐service plan. This paper focuses on a conventional fee‐for‐service plan including a mandatory access to a telemedicine service; the insured are obliged to phone this medical call centre before visiting a physician. This type of plan generates much lower average health expenditures than a conventional insurance plan. Reasons for this may include selection, incentive effects or efficiency. In our sample, about 90% of the difference in health expenditure can be explained by selection and incentive effects. The remaining 10% of savings due to the efficiency of the telemedicine service amount to about SFr 150 per year per insured, of which approximately 60% is saved by the insurer and 40% by the insured. Although the efficiency effect is greater than the cost of the plan, the big winners are the insured who not only save monetary and non‐monetary costs but also benefit from reduced premiums. Copyright © 2010 John Wiley & Sons, Ltd.     

城乡居民医保、老年人健康与医疗服务利用——来自五期CLHLS数据的证据

医疗保险作为我国社会保险制度的重要组成部分,其能否有效改善参保人的健康水平及医疗服务利用状况一直是国内外学者们争论的焦点。本研究基于2005—2018年中国老年健康影响因素跟踪调查的五期平衡面板数据,运用固定效应模型等方法,分析城乡居民医保对参保老年人健康水平及医疗服务利用状况的影响。研究发现,参加城乡居民医保并不能有效改善老年人的健康水平,但却可以改善他们的医疗服务利用状况,且对身体健康状况出现恶化的老年人影响更大。除此之外,本文并未发现支持城乡居民医保影响存在滞后的证据。基于此,本文认为我国城乡居民医保制度的实际效果与其预期目标间仍存在一定的差距。在我国医保扩面工作已取得长足进展的基础上,未来我国的城乡居民医保制度建设应将重心转移至进一步提高保障水平、实现可持续发展上,提升城乡居民医保的综合待遇,重视发挥医保的疾病预防功能。     

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.     

Rural-Urban Differences in Health Care Benefits of a Community-Based Sample of At-Risk Drinkers

CONTEXT: Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas. PURPOSE: This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas. METHODS: A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies. FINDINGS: Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees. CONCLUSIONS: Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.     

Will uninsured people volunteer for voluntary health insurance? Experience from Washington State.

OBJECTIVES: In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should be mandatory or voluntary. This study describes characteristics of low- income people who were more likely or less likely to be covered by a voluntary plan. METHODS: Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics. RESULTS: There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance. CONCLUSIONS: If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care.     

Children's health services in a "system of care": patterns of mental health, primary and specialty use

OBJECTIVES: This study was designed to investigate demonstrable impacts of the Mental Health Services Program for Youth (MHSPY), a highly coordinated, intentionally integrated "system of care," on patterns of health service utilization for youth with multiple needs. METHODS: The MHSPY intervention is available to a target population of urban youth who face barriers to health care and are at risk for out-of-home placement. These youth are enrolled in a non-profit managed care organization (MCO). Patterns of medical, pharmacy, and mental health and substance abuse service use were compared for children aged 3 to 19 across insurance categories. RESULTS: Despite risks for access and engagement barriers to care, and for greater medical expense due to greater morbidity, MHSPY enrollees received significantly more ambulatory care per person-year than either the privately insured population or the Medicaid Standard population, and medical expense for MHSPY members was significantly lower than expected. During the four years studied, individuals in the privately insured and Medicaid Standard populations were less likely than MHSPY enrollees to have had an ambulatory pediatric visit (odds ratio [OR] 0.833, 95% confidence interval [CI] 0.765, 0.908 and OR 0.823, 95% CI 0.775, 0.897, respectively). Medical expenses per member per month for MHSPY enrollees were significantly less than that for the similarly impaired Medicaid Disabled population with any medical claim (p < 0.001) or with any outpatient mental health claim (p < 0.01). CONCLUSIONS: Patterns of health care for subpopulations with known risk are important to identify to evaluate system-of-care effectiveness. The service utilization patterns for youth enrolled in the MHSYP system of care vs. those for similar MCO youth suggest health care access for individuals can be affected by delivery system design variables.     

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.     

Improvements in Health Behaviors and Health Status Among Newly Insured Members of an Innovative Health Access Plan

The Healthy Howard Health Plan (HHHP) is an innovative health access plan providing healthcare and health coaching to previously uninsured adults in Howard County, Maryland. HHHP members who enrolled in HHHP between January 2009 to June 2010 are followed over time using a variety of self-reported data collection tools including a health risk assessment (HRA), the SF-12, a measure of health status, and the PAM, patient activation measure. We describe their unmet health needs, demographics, health status and behaviors at baseline and we describe changes in health-related behaviors over time. Demographic and baseline HRA results for 700 individuals who enrolled over the first 18 months reveal HHHP members generally were racially diverse (white: 37 %; African American: 23 %, and Asian: 30 %), married (50 %) females (59 %). Most (62 %) have a family income between 121 and 200 % of the federal poverty level, and were without health insurance for more than 1 year (56 %). Self-reported health and behaviors for 163 plan members who completed initial and follow up HRAs revealed increases in physical activity, fruit and vegetable consumption, and health status. Statistically significant differences were found in patient activation from baseline to follow up (44 vs 58 %, p value 0.0005). Patient demographics, health status, and health behaviors of these newly insured Americans may help policy makers and care providers prepare to meet their needs. We noted improvements in certain self-reported health behaviors and health status, suggesting participation in the Plan is associated with positive health impacts for some Plan members.     

不同管理体制下城乡居民基本医疗保险运行效果比较——来自苏州市的实证分析

目的：实证分析不同管理体制下城乡居民基本医疗保险的运行效果。方法：以苏州市下辖的常熟市及其他三个县级市作为研究对象,运用描述性统计和比较分析的方法分析城乡居民基本医疗保险运行情况。结果：与其他三个县级市相比较,常熟市参保人员利用市外住院服务比例较低,城乡居民医保住院统筹基金流向市外医疗机构的比例较低,住院补偿受益率相对较高,参保患者的自付住院费用较低,但住院实际补偿比较低。结论：医保的管理体制未对医保覆盖面和基金运行产生明显影响;卫生部门主管有助于更好地坚持“保基本、强基层、建机制”的原则,可以更好地控制医疗费用的上涨速度,减轻患者的医疗负担。建议：进一步扩大医保管理体制改革的试点,为完善我国医保管理体制提供更多的实证依据;同时注重控制医药费用的上涨速度,以降低参保人员的医疗负担;建立健全城乡居民基本医疗保险的评价指标。     

Urban and Rural Differences in Health Insurance and Access to Care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies.
Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis.
Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.     

中国长期照护保险制度的地区比较与思考

本文通过对青岛等13个国家级试点城市和北京市海淀区已出台的长期照护保险相关政策进行梳理,总结各地长期照护保险面临的问题与挑战,并提出对长期照护保险制度建设过程中的福利化与市场化、长期照护保险与医疗保险的关系、具体实施方案等问题的初步思考。根据各试点地区和海淀区已出台文件中有关长期照护保险的基本内容,发现它们在保障对象、筹资来源、评定和保障方式、保障金额、保障内容等方面既有共性,也存在差异。本文认为,虽然各试点地区的长期照护保险制度已初步建立,但在监督管理、护理服务提供等方面的具体实施方案还有待论证;此外,各地还需要不断扩大长期照护保险的受益范围,做好长期照护保险与养老保险、医疗保险的协调与衔接,合理配置医疗、养老和照护资源。     

Health Insurance and Health Care among the Mid‐Aged and Older Chinese: Evidence from the National Baseline Survey of CHARLS

We document the recent profile of health insurance and health care among mid‐aged and older Chinese using data from the China Health and Retirement Longitudinal Study conducted in 2011. Overall health insurance coverage is about 93%. Multivariate regressions show that respondents with lower income as measured by per capita expenditure have a lower chance of being insured, as do the less‐educated, older, and divorced/widowed women and rural‐registered people. Premiums and reimbursement rates of health insurance vary significantly by schemes. Inpatient reimbursement rates for urban people increase with total cost to a plateau of 60%; rural people receive much less. Demographic characteristics such as age, education, marriage status, per capita expenditure, and self‐reported health status are not significantly associated with share of out‐of‐pocket cost after controlling community effects. For health service use, we find large gaps that vary across health insurance plans, especially for inpatient service. People with access to urban health insurance plans are more likely to use health services. In general, Chinese people have easy access to median low‐level medical facilities. It is also not difficult to access general hospitals or specialized hospitals, but there exists better access to healthcare facilities in urban areas. Copyright © 2016 John Wiley & Sons, Ltd.