Increasing health insurance costs and the decline in insurance coverage

OBJECTIVE: To determine the impact of rising health insurance premiums on coverage rates. DATA SOURCES & STUDY SETTING: Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989-1991 and 1998-2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. STUDY DESIGN: Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates. PRINCIPAL FINDINGS: More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9-6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1-3 percentage points, holding all else constant. CONCLUSIONS: Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.     

Effects of health insurance coverage on risky behaviors

Prior to implementation of the Patient Protection and Affordable Care Act, dependent health insurance coverage was typically available only for young adults under the age of 19. As of September 2010, the Affordable Care Act extended dependent health insurance coverage to include young adults up to the age of 26. I use the National Health Interview Survey for the sample period from 2011 to 2013 to analyze the causal relationship between the expansion of dependent coverage and risky behaviors including smoking and drinking as well as preventive care. I employ a regression discontinuity design to estimate the causal effect of health insurance coverage and overcome the endogeneity problem between insurance status and risky behaviors. When young adults become 26 years old, they are 7 to 10 percentage points more likely to lose health insurance than young adults under the age of 26. Although young adults over the age of 26 are generally aged out of insurance coverage, presence or absence of health insurance does not affect their smoking and drinking behaviors and their access to preventive care.     

The impact of the tax system on health insurance coverage

A central question in health economics is the extent to which this tax subsidization matters for the health insurance coverage of the U.S. population. I assess the impact of taxes on health insurance by using the considerable existing variation in tax subsidies, both at a point in time and across time. I do so by putting together data from more than a decade of Current Population Survey (CPS) data sets, and matching to workers in those data sets their tax subsidies to health insurance coverage. I find that the elasticity of insurance eligibility of workers is at least –0.6, and that the elasticity of own insurance coverage is roughly similar; the results imply that most of the impact of taxes on insurance coverage arise through firm offering and eligibility decisions. I also find that higher tax rates induce more private coverage through other sources, but less public coverage, so that overall there is a reduction in the rate of uninsurance that is comparable to the change in own employer-provided insurance coverage.     

Health Insurance,Health Savings Accounts and Healthcare Utilization

Assuming symmetric information, we show that a high‐deductible health plan (HDHP) combined with a tax‐favored health savings account (HSA) induces more savings and less treatment compared with a full coverage plan under reasonable risk preferences. Furthermore, a higher tax subsidy increases savings in any case but decreases medical utilization if and only if treatment expenses are above the deductible. A larger deductible increases savings but does not necessarily decrease healthcare utilization. Whether an HDHP/HSA combination is preferred over a full coverage contract depends on absolute risk aversion. A higher tax advantage increases the attractiveness of an HDHP/HSA combination, whereas the effects of changes in the deductible are ambiguous. The paper shows that a potential regulator needs to carefully set the size of the deductible as only in a certain corridor of the probability of sickness, its effect on aggregate healthcare costs are unambiguously favorable. Copyright © 2015 John Wiley & Sons, Ltd.     

The impact of survey attrition on health insurance coverage estimates in a National Longitudinal Health Care Survey

Timely, accurate and reliable estimates of the population’s health insurance status are essential inputs to policymakers to inform assessments of the population’s access to medical care and analyses of associated health care expenditures. Alternative criteria that have been used to produce annual estimates of the uninsured include the following specifications: those uninsured for a full-year, those ever uninsured during a year, and those uninsured at a specific point in time. The Medical Expenditure Panel Survey (MEPS), one of the core health care surveys in the United States, supports all three types of estimates. In this paper, a summary is provided of the survey operations, informational materials, the interviewer training and experience of the field force, and the refusal conversion techniques employed in the MEPS to maintain respondent cooperation for five rounds of interviewing, to help minimize sample attrition. The impact of nonresponse attributable to survey attrition is also assessed with respect to the national health insurance coverage estimates derived from the MEPS. The study includes an examination of the quality of the nonresponse adjustments employed to adjust for potential nonresponse bias attributable to survey attrition. The overlapping panel design of the MEPS survey is particularly well suited to inform these studies. The presentation concludes with a discussion of strategies under consideration that may yield additional improvements in the accuracy for these critical policy relevant survey estimates.     

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.     

Health insurance coverage within sibships: Prevalence of mixed coverage and associations with health care utilization

An increasing proportion of children in the United States lives in families with complicated family structures and a mix of immigrant and US-born family members. Eligibility rules for health insurance coverage, however, were not designed with these families in mind. The result can be complicated insurance patterns among siblings within families, with some “sibships” only being partially-insured, and other sibships having both private and public coverage. We hypothesize that mixed coverage among siblings causes confusion and logistical difficulties for parents and may lead to less access to appropriate health care for their children. In this article, we use data from the 2009–2011 National Health Interview Survey (n = 51,418 children in 20,478 sibships) to present estimates of the prevalence of mixed health insurance coverage among siblings and describe the predictors of such coverage. We also use linked data from the 2001–2005 National Health Interview Survey and 2002–2007 Medical Expenditure Panel Survey (n = 17,871) to show how mixed coverage is related to health care utilization. We find that although few sibships are characterized by different health insurance coverage types, mixed coverage among siblings is far more common among families with mixed nativity status, and blended families with step- and half-siblings. In terms of outcomes, children living in sibships with mixed coverage have significantly lower odds of having a usual source of health care. We also consider whether the association between mixed insurance coverage and health care outcomes differs across particular combinations of insurance coverage. We find that both publicly-insured children who have uninsured siblings and privately-insured children with publicly-insured siblings are less likely to have a usual source of care than similar children with uniformly-insured siblings. Because a usual source of care is associated with better health care outcomes, we argue that policymakers should consider ways to reduce mixed coverage among children and families.     

The effect of health insurance coverage on medical care utilization and health outcomes: Evidence from Medicaid adult vision benefits

Increasing the proportion of adults that have regular, comprehensive eye exams and reducing visual impairment due to uncorrected refractive error and other common eye health problems are federal health objectives. We examine the effect of vision insurance on eye care utilization and vision health outcomes by taking advantage of quasi-experimental variation in Medicaid coverage of adult vision care. Using a difference-in-difference-in-difference approach, we find that Medicaid beneficiaries with vision coverage are 4.4 percentage points (p < 0.01) more likely to have seen an eye doctor in the past year, 5.3 percentage points (p < 0.01) less likely to report needing but not purchasing eyeglasses or contacts due to cost, 2.0 percentage points (p < 0.05) less likely to report difficulty seeing with usual vision correction, and 1.2 percentage points (p < 0.01) less likely to have a functional limitation due to vision.     

医疗保险制度对降低我国居民灾难性卫生支出的效果分析

目的：2008年中国的医保制度已经覆盖87.9%的居民,接近全民医保覆盖的目标。然而,仍存在部分居民现金卫生支出比例过高的现象,导致家庭由于支付医疗卫生费用而陷入经济困境。本文通过计算中国灾难性卫生支出发生率和致贫率,来探究中国医疗保险制度的保障力度与水平。方法：本文利用第四次卫生服务调查的数据,通过世界卫生组织推荐的方法计算灾难性卫生支出和致贫率。结果：灾难性卫生支出发生率为13.0%,且发生率随着家庭经济水平的提高而降低;总体致贫率为7.5%;家庭中含有住院病人、慢性病人、肺结核病人及60岁以上老人,其发生灾难性卫生支出的风险高。结论与建议：通过分析脆弱人群发生灾难性卫生支出风险及影响因素,为今后完善医疗保险制度设计提供具有可操作性的政策建议,增强其对居民抵御疾病经济风险的保障能力。     

The dynamics of health insurance coverage: identifying trigger events for insurance loss and gain

By linking consecutive years of the 1996–2004 Current Population Survey (CPS), we create new estimates of annual transitions into and out of health insurance coverage. Using the matched CPS panel data, we explore the dynamic factors—including job loss, changes in hours or weeks worked, and movement between firm sizes—associated with health insurance loss and gain. Job loss is strongly associated with losing insurance, whereas becoming reemployed is only weakly associated with gaining insurance. Movement down (up) in employment size is associated with insurance loss (gain), but movement to employers with fewer than 10 employees is associated with especially high rates of loss. Changes in hours or weeks worked and employment type are also strongly associated with insurance transitions.

The likely effects of employer-mandated complementary health insurance on health coverage in France

In France, access to health care greatly depends on having a complementary health insurance coverage (CHI). Thus, the generalisation of CHI became a core factor in the national health strategy created by the government in 2013. The first measure has been to compulsorily extend employer-sponsored CHI to all private sector employees on January 1st, 2016 and improve its portability coverage for unemployed former employees for up to 12 months. Based on data from the 2012 Health, Health Care and Insurance survey, this article provides a simulation of the likely effects of this mandate on CHI coverage and related inequalities in the general population by age, health status, socio-economic characteristics and time and risk preferences. We show that the non-coverage rate that was estimated to be 5% in 2012 will drop to 4% following the generalisation of employer-sponsored CHI and to 3.7% after accounting for portability coverage. The most vulnerable populations are expected to remain more often without CHI whereas non coverage will significantly decrease among the less risk averse and the more present oriented. With its focus on private sector employees, the policy is thus likely to do little for populations that would benefit most from additional insurance coverage while expanding coverage for other populations that appear to place little value on CHI.     

Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage

South Korea introduced mandatory social health insurance forindustrial workers in large corporations in 1977, and extendedit incrementally to the self-employed until it covered the entirepopulation in 1989. Thirty years of national health insurancein Korea can provide valuable lessons on key issues in healthcare financing policy which now face many low- and middle-incomecountries aiming to achieve universal health care coverage,such as: tax versus social health insurance; population andbenefit coverage; single scheme versus multiple schemes; purchasingand provider payment method; and the role of politics and politicalcommitment. National health insurance in Korea has been successfulin mobilizing resources for health care, rapidly extending populationcoverage, effectively pooling public and private resources topurchase health care for the entire population, and containinghealth care expenditure. However, there are also challengesposed by the dominance of private providers paid by fee-for-service,the rapid aging of the population, and the public-private mixrelated to private health insurance.     

The spillover effects of health insurance benefit mandates on public insurance coverage: Evidence from veterans

This study examines how regulations in private health insurance markets affect coverage of public insurance. We focus on mental health parity laws, which mandate private health insurance to provide equal coverage for mental and physical health services. The implementation of mental health parity laws may improve a quality dimension of private health insurance but at increased costs. We graphically develop a conceptual framework and then empirically examine whether the regulations shift individuals from private to public insurance. We exploit state-by-year variation in policy implementation in 1999–2008 and focus on a sample of veterans, who have better access to public insurance than non-veterans. Using data from the Current Population Survey, we find that the parity laws reduce employer-sponsored insurance (ESI) coverage by 2.1% points. The drop in ESI is largely offset by enrollment gains in public insurance, namely through the Veterans Affairs (VA) benefit and Medicaid/Medicare programs.     

The Affordable Care Act's insurance market regulations' effect on coverage

Much of the debate surrounding reform of the Patient Protection and Affordable Care Act (ACA) revolves around its insurance market regulation. This paper studies the impact on health insurance coverage of those provisions. Using data from the American Community Survey, years 2008–2015, I focus on individuals, ages 26 to 64, who are ineligible for the subsidies or Medicaid expansions included in the ACA to isolate the effect of its market regulation. To account for time trends, I utilize a differences‐in‐differences approach with a control group of residents of Massachusetts who were already subject to a similarly regulated health insurance market. I find that the ACA's regulations caused an increase of 0.95 percentage points in health insurance coverage for my sample in 2014. This increase was concentrated among younger individuals, suggesting that the law's regulations ameliorated adverse selection in the individual health insurance market.     

Worker preferences, sorting and aggregate patterns of health insurance coverage

To assess the performance of the employment-based health insurance system, it is necessary to understand how well workers sort into jobs that offer their desired mix of cash wages relative to benefits. However, few studies directly measure the extent of sorting. We quantify the prevalence of mismatches between workers’ preferences and firms’ insurance offerings by considering two types of mismatch: (1) workers who appear to desire coverage through their employer, but work for firms that do not offer coverage, and; (2) workers who appear not to desire coverage through their employer, but work for firms that offer coverage. Most workers (79.6%) enjoy labor market matches that appear consistent with their preferences. The remaining 20.4% of workers appear to be mismatched. For most of these mismatches, the primary consequence is lower wages than would be earned if individuals were better matched in the labor market. However, a minority of the identified mismatches appear to be “involuntarily uninsured” workers who would gain insurance if they were to find a better match. Extrapolating from the analysis sample, these involuntarily uninsured workers and their uninsured dependents may represent up to one in six uninsured individuals in the United States. This work was supported by a grant from the Economic Research Initiative on the Uninsured (ERIU) at the University of Michigan, funded by the Robert Wood Johnson Foundation.     

The adequacy of household survey data for evaluating the nongroup health insurance market

OBJECTIVE: To evaluate the accuracy of household survey estimates of the size and composition of the nonelderly population covered by nongroup health insurance. DATA SOURCES/STUDY SETTING: Health insurance enrollment statistics reported to New Jersey insurance regulators. Household data from the following sources: the 2002 Current Population Survey (CPS)-March Demographic Supplement, the 1997 and 1999 National Surveys of America's Families (NSAF), the 2001 New Jersey Family Health Survey (NJFHS), a 2002 survey of known nongroup health insurance enrollees, a small 2004 survey testing alternative health insurance question wording. STUDY DESIGN: To assess the extent of bias in estimates of the size of the nongroup health insurance market in New Jersey, enrollment trends are compared between official enrollment statistics reported by insurance carriers to state insurance regulators with estimates from three general population household surveys. Next, to evaluate possible bias in the demographic and socioeconomic composition of the New Jersey nongroup market, distributions of characteristics of the enrolled population are contrasted among general household surveys and a survey of known nongroup subscribers. Finally, based on inferences drawn from these comparisons, alternative health insurance question wording was developed and tested in a local survey to test the potential for misreporting enrollment in nongroup coverage in a low-income population. DATA COLLECTION/EXTRACTION METHODS: Data for nonelderly New Jersey residents from the 2002 CPS (n=5,028) and the 1997 and 1999 NSAF (n=6,467 and 7,272, respectively) were obtained from public sources. The 2001 NJFHS (n=5,580 nonelderly) was conducted for a sample drawn by random digit dialing and employed computer-assisted telephone interviews and trained, professional interviewers. Sampling weights are used to adjust for under-coverage of households without telephones and other factors. In addition, a modified version of the NJFHS was administered to a 2002 sample of known nongroup subscribers (n=1,398) using the same field methods. These lists were provided by four of the five largest New Jersey nongroup insurance carriers, which represented 95 percent of all nongroup enrollees in the state. Finally, a modified version of the NJFHS questionnaire was fielded using similar methods as part of a local health survey in New Brunswick, New Jersey, in 2004 (n=1,460 nonelderly). PRINCIPAL FINDINGS: General household sample surveys, including the widely used CPS, yield substantially higher estimates of nongroup enrollment compared with administrative totals and yield estimates of the characteristics of the nongroup population that vary greatly from a survey of known nongroup subscribers. A small survey testing a question about source of payment for direct-purchased coverage suggests than many public coverage enrollees report nongroup coverage. CONCLUSIONS: Nongroup health insurance has been subject to more than a decade of reform and is of continuing policy interest. Comparisons of unique data from a survey of known nongroup subscribers and administrative sources to household surveys strongly suggest that the latter overstates the number and misrepresent the composition of the nongroup population. Research on the nongroup market using available sources should be interpreted cautiously and survey methods should be reexamined.     

The income distributive implications of recent private health insurance policy reforms in Australia

The Australian government implemented a series of private health insurance (PHI) policy reforms between 1997 and 2000. As a result, the proportion of the population with PHI coverage increased by more than 35%. However, this study found significant evidence that the policy reform disproportionately favours high-income earners. In particular, the 30% premium subsidy represents a windfall gain for households which would have purchased PHI even without the rebate. The amount of such gain is estimated to be around $900 million per year, a large proportion of which went to higher income households.