Long-term care use and socio-economic status in Belgium: a survival analysis using health care insurance data

Background

The small but growing literature on socio-economic inequality in morbidity among older persons suggests that social inequalities in health persist into old age. A largely separate body of literature looks at the predictors of long-term care use, in particular of institutional care. Various measures of socio-economic status are often included as control variables in these studies. Review articles generally conclude that the evidence for such variables being a predictor for institutionalization is “inconclusive”. In this paper we look at the association among older persons in Belgium between one particular measure of socio-economic status – preferential status in public health care insurance – and first use of home long-term care and residential care. Preferential status entitles persons to higher reimbursement rates for health care from the public health care insurance system and is conditional on low income. We also study whether preferential status is related to the onset of five important chronic conditions and the time of death.

Methods

We use survival analysis; the source of the data is a large administrative panel of a sample representative for all older persons in Belgium (1,268,740 quarterly observations for 69,562 individuals).

Results

We find a strong association between preferential status and the likelihood of home care use, but for residential care it is small for men and non-existent for women. We also find that preferential status is significantly related to the chance of getting two out five chronic conditions – COPD and diabetes, but not dementia, hip fracture and Parkinson’s disease – and to the probability of dying (not for women). For home care use and death, the association with preferential status declines with increasing age from age 65 onwards, such that it is near zero for those aged around 90 and older.

Conclusion

We find clear associations between an indicator of low income and home care use, some chronic conditions and death. The associations are stronger among men than among women. We also find that the association declines with age for home care use and death, which might be explained by selective survival.     

Relationships between welfare status,health insurance status,and health and medical care among children with asthma

OBJECTIVES: This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma. METHODS: Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices. RESULTS: Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured. CONCLUSIONS: Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.     

Switching Swiss enrollees from indemnity health insurance to managed care: the effect on health status and stisfaction with care.

OBJECTIVES. In 1992, most members of a Swiss indemnity health insurance plan were automatically transferred into a newly created managed care organization. This study examined whether this semivoluntary change affected enrollees' health status and satisfaction with care. METHODS. Three groups of enrollees were compared: 332 plan members who accepted the switch (managed care joiners); 186 plan members who opted to maintain indemnity coverage (non-joiners); and 296 persons continuosly enrolled in another indemnity plan (indemnity plan members). Health status, health related behaviors, and satisfaction with care received in the previous year were surveyed at baseline and 1 year later. RESULTS. Health status remained unchanged in all three groups. Smoking prevalence decreased among managed care joiners but remained constant in the other groups. Satisfaction with insurance coverage increased between baseline and follow-up in managed care joiners, but decreased in nonjoiners and indemnity plan members. The latter groups had higher satisfaction with health care, particularly with continuity of care. CONCLUSIONS. A semivoluntary switch from indemnity health insurance to managed care reduced satisfaction with health care but increased satisfaction with insurance coverage. There were no changes in self-perceived health status.     

Health status, health insurance, and health care utilization patterns of immigrant Black men

OBJECTIVES: This study sought to describe the health status, health insurance, and health care utilization patterns of the growing population of immigrant Black men. METHODS: We used data from the 1997-2000 National Health Interview Survey to examine and then compare health variables of foreign-born Black men with those of US-born Black and White men. Logistic regression analyses were used to examine health outcomes. RESULTS: Foreign-born Black men were in better overall health than their US-born Black counterparts and were much less likely than either US-born Black or White men to report adverse health behaviors. Despite these health advantages, foreign-born Black men were more likely than either US-born Black or White men to be uninsured. CONCLUSIONS: In the long term, immigrant Black men who are in poor health may be adversely affected by lack of health care coverage.     

Medical insurance and the use of health care services by the elderly

The objective of this paper is to find how health insurance influences the use of health care services by the elderly. On the basis of the first wave of the Asset and Health Dynamics Survey, we find that those who are the most heavily insured use the most health care services. Because our data show little relationship between observable health measures and either the propensity to hold or to purchase private insurance, we interpret this as an effect of the incentives embodied in the insurance, rather than as the result of adverse selection in the purchase of insurance.     

唐山市农民工医疗保障现状及参保意愿研究

文章对唐山市农民工的医疗保障现状及参保意愿进行了调查.结果显示:农民工参保意愿较强烈,但实际参保率低;农民工是否愿意参加医疗保险以及愿意参加哪种医疗保险模式,受多种因素影响.为此,建议农民工医疗保障政策的制定应充分考虑农民工的现实情况和参保意愿.     

Motherhood, health status, and health care.

This study examines the impact of multiple roles and stressors on women of childbearing age, and compares the health status of women with and without children and their ability to access health care. Motherhood has many complex interactions with income level, availability of health insurance, and available social and income support. A cumulative burden of multiple stressors (eg, being poor, uninsured, less educated, employed full-time, or being a single mother) relates to worse health status, levels of depression, and opportunities for obtaining health care. Multiple stressors seem to have a stronger effect on mothers than on nonmothers. Research should focus on identifying vulnerable groups and combinations of stressors for women both with and without children, and how to mitigate adverse impacts on physical and mental health.     

Family planning clinic patients: their usual health care providers, insurance status, and implications for managed care.

PURPOSE: To understand the extent to which family planning clinic patients have health insurance or access to other health care providers, as well as their preferences for clinic versus private reproductive medical care. METHOD: An anonymous self-report questionnaire was administered at three Planned Parenthood clinics in Los Angeles County to 780 female patients aged 12-49 years. Dependent variables included insurance status, usual source of care, and a battery of questions regarding the importance of confidentiality. RESULTS: A total of 356 adolescents (aged 12-19 years) and 424 adults (aged 20-49 years) completed the survey in 1994. Fifty-nine percent of adolescents and 53% of adults had a usual source of care other than the clinic. The majority of each group reported some degree of continuity of care in their usual provider setting. Nearly half (49%) of all adolescents had health insurance compared with 27% of adults. Adolescents cited not wanting to involve family members as the primary reason for not using their usual providers, whereas adults were more likely to cite being uninsured. The majority of both adult and adolescent patients indicate they would prefer the clinic over private health care if guaranteed health care that was free, confidential, or both. CONCLUSION: Despite many patients' having health insurance and other sources of health care, family planning clinics were primarily chosen because of cost and confidentiality. Their reasons for preferring clinics may continue despite changes in access to insurance or efforts to incorporate similar reproductive services into mainstream health care provider systems. Making public or private health care funds available to family planning clinics through contracts or other mechanisms may facilitate patients' access to essential services and reduce potential service duplication.     

Legal status and health insurance among immigrants

The foreign-born represent a disproportionate share of nonelderly U.S. adults without health insurance. Using data from Los Angeles County, we find that most of the insurance disparities between the foreign-born and native-born can be explained by traditional socioeconomic factors. Undocumented immigrants, however, have lower rates of coverage-both private and public-even after a wide array of factors are controlled for. Applying Los Angeles County rates to the U.S. population implies that undocumented immigrants account for one-third of the total increase in the number of uninsured adults in the United States between 1980 and 2000.     

Low-income Californians' experiences with health insurance and managed care.

California is rapidly implementing mandatory managed care for most of its Medicaid (Medi-Cal) beneficiaries. To assess the impact of this delivery system change, the authors analyzed a 1996 statewide population-based random-sample telephone survey of 3,563 adults between the ages of 18 and 64. Respondents with Medi-Cal managed care and Medi-Cal fee-for-service rated access to care and quality of care significantly higher than uninsured respondents yet lower than low-income privately insured individuals. While the authors did not find a difference in health care access and quality among Medi-Cal managed care enrollees compared with Medi-Cal fee-for-service enrollees, they also did not find that managed care provided any observed advantages to Medi-Cal recipients.     

Captive insurance companies in health care

A health care system or individual hospital should consider establishing a captive insurance company if any one of the following situations exist: The organization's professional liability program is arranged with a self-insured retention of $500,000 or more, or consideration is being given to such an arrangement. A trust fund has been established for a self-insured exposure--professional liability, workers' compensation, or employee benefits. A portion of the organization's professional liability excess insurance program is arranged with an insurer that uses a fronting insurer. The organization currently sponsors, or is considering sponsoring, a physicians' liability insurance program for medical staff members. If any of those situations exist, a comprehensive feasibility study should be undertaken, preferably by an independent, objective organization that does not have a financial interest in the outcome of the study.     

How health insurance inhibits trade in health care

A range of health care services are tradable, in that consumers can travel abroad for treatment. In this paper we first estimate the gains from trade. An international price comparison of fifteen procedures reveals that there could be savings of around 1.4 billion dollars annually even if only one in ten U.S. patients choose to undergo treatment abroad. We then identify a key impediment to realizing these gains: the nature of existing health insurance plans, which discriminate explicitly or implicitly against treatment abroad. We propose that coverage should be neutral to provider location and that reimbursement should include travel costs.