The American Community Survey and Health Insurance Coverage Estimates: Possibilities and Challenges for Health Policy Researchers

Objective. To introduce the American Community Survey (ACS) and its measure of health insurance coverage to researchers and policy makers.
Data Sources/Study Setting. We compare the survey designs for the ACS and Current Population Survey (CPS) that measure insurance coverage.
Study Design. We describe the ACS and how it will be useful to health policy researchers.
Principal Findings. Relative to the CPS, the ACS will provide more precise state and substate estimates of health insurance coverage at a point-in-time. Yet the ACS lacks the historical data and detailed state-specific coverage categories seen in the CPS.
Conclusions. The ACS will be a critical new resource for researchers. To use the new data to the best advantage, careful research will be needed to understand its strengths and weaknesses.     

An Examination of the Medicaid Undercount in the Current Population Survey: Preliminary Results from Record Linking

Objective. To assess reasons why survey estimates of Medicaid enrollment are 43 percent lower than raw Medicaid program enrollment counts (i.e., Medicaid undercount).
Data Sources. Linked 2000–2002 Medicaid Statistical Information System (MSIS) and the 2001–2002 Current Population Survey (CPS).
Data Collection Methods. Centers for Medicare and Medicaid Services provided the Census Bureau with its MSIS file. The Census Bureau linked the MSIS to the CPS data within its secure data analysis facilities.
Study Design. We analyzed how often Medicaid enrollees incorrectly answer the CPS health insurance item and imperfect concept alignment (e.g., inclusion in the MSIS of people who are not included in the CPS sample frame and people who were enrolled in Medicaid in more than one state during the year).
Principal Findings. The extent to which the Medicaid enrollee data were adjusted for imperfect concept alignment reduces the raw Medicaid undercount considerably (by 12 percentage points). However, survey response errors play an even larger role with 43 percent of Medicaid enrollees answering the CPS as though they were not enrolled and 17 percent reported being uninsured.
Conclusions. The CPS is widely used for health policy analysis but is a poor measure of Medicaid enrollment at any time during the year because many people who are enrolled in Medicaid fail to report it and may be incorrectly coded as being uninsured. This discrepancy should be considered when using the CPS for policy research.     

The Effect of Response Scale,Administration Mode,and Format on Responses to the CAHPS Clinician and Group Survey

Objective

To examine how different response scales, methods of survey administration, and survey format affect responses to the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Clinician and Group (CG-CAHPS) survey.

Study Design

A total of 6,500 patients from a university health center were randomly assigned to receive the following: standard 12-page mail surveys using 4-category or 6-category response scales (on CG-CAHPS composite items), telephone surveys using 4-category or 6-category response scales, or four-page mail surveys.

Principal Findings

A total of 3,538 patients completed surveys. Composite score means and provider-level reliabilities did not differ between respondents receiving 4-category or 6-category response scale surveys or between 12-page and four-page mail surveys. Telephone respondents gave more positive responses than mail respondents.

Conclusions

We recommend using 4-category response scales and the four-page mail CG-CAHPS survey.     

The Impact of the Macroeconomy on Health Insurance Coverage: Evidence from the Great Recession

This paper investigates the impact of the macroeconomy on the health insurance coverage of Americans using panel data from the Survey of Income and Program Participation for 2004–2010, a period that includes the Great Recession of 2007–2009. We find that a one percentage point increase in the state unemployment rate is associated with a 1.67 percentage point (2.12%) reduction in the probability that men have health insurance; this effect is strongest among college‐educated, white, and older (50–64 years old) men. For women and children, health insurance coverage is not significantly correlated with the unemployment rate, which may be the result of public health insurance acting as a social safety net. Compared with the previous recession, the health insurance coverage of men is more sensitive to the unemployment rate, which may be due to the nature of the Great Recession. Copyright © 2013 John Wiley & Sons, Ltd.     

Accelerating Improvement and Narrowing Gaps: Trends in Patients' Experiences with Hospital Care Reflected in HCAHPS Public Reporting

Objective

Measure HCAHPS improvement in hospitals participating in the second and fifth years of HCAHPS public reporting; determine whether change is greater for some hospital types.

Data

Surveys from 4,822,960 adult inpatients discharged July 2007–June 2008 or July 2010–June 2011 from 3,541 U.S. hospitals.

Study Design

Linear mixed‐effect regression models with fixed effects for time, patient mix, and hospital characteristics (bedsize, ownership, Census division, teaching status, Critical Access status); random effects for hospitals and hospital‐time interactions; fixed‐effect interactions of hospital characteristics and patient characteristics (gender, health, education) with time predicted HCAHPS measures correcting for regression‐to‐the‐mean biases.

Data Collection Methods

National probability sample of adult inpatients in any of four approved survey modes.

Principal Findings

HCAHPS scores increased by 2.8 percentage points from 2008 to 2011 in the most positive response category. Among the middle 95 percent of hospitals, changes ranged from a 5.1 percent decrease to a 10.2 percent gain overall. The greatest improvement was in for‐profit and larger (200 or more beds) hospitals.

Conclusions

Five years after HCAHPS public reporting began, meaningful improvement of patients'' hospital care experiences continues, especially among initially low‐scoring hospitals, reducing some gaps among hospitals.     

合肥市某区社区医生吸烟及控烟状况调查

目的了解合肥市某区社区卫生服务机构医务人员吸烟状况及相关知识和行为,为控烟工作提供依据。方法使用统一问卷,采用询问和自填的方式调查合肥市某区25家社区卫生服务机构所有医务工作人员。结果该区社区卫生服务机构医务人员现在吸烟率为17.5%,戒烟率6.5%。医务人员对吸烟与被动吸烟引起肺部疾病等常见危害认知较高,但对吸烟与被动吸烟对其他器官的危害性了解不多。72.5%的医务人员未参加过戒烟培训。结论应加强社区卫生服务机构医务人员烟草危害知识的宣传教育及戒烟技能培训,充分发挥社区卫生服务机构在控烟中的作用。     

Health Insurance Costs and Employee Compensation: Evidence from the National Compensation Survey

This paper examines the relationship between rising health insurance costs and employee compensation. I estimate the extent to which total compensation decreases with a rise in health insurance costs and decompose these changes in compensation into adjustments in wages, non‐health fringe benefits, and employee contributions to health insurance premiums. I examine this relationship using the National Compensation Survey, a panel dataset on compensation and health insurance for a sample of establishments across the USA. I find that total hourly compensation reduces by $0.52 for each dollar increase in health insurance costs. This reduction in total compensation is primarily in the form of higher employee premium contributions, and there is no evidence of a change in wages and non‐health fringe benefits. These findings show that workers are absorbing at least part of the increase in health insurance costs through lower compensation and highlight the importance of examining total compensation, and not just wages, when examining the relationship between health insurance costs and employee compensation. Copyright © 2016 John Wiley & Sons, Ltd.     

柳州市社区居民首次健康素养调查结果分析

目的了解柳州市居民健康素养现状,为健康教育工作的开展及效果评价提供科学的依据。方法以整群随机抽样的方法,以本市500名15~69岁城市常住居民作为调查对象开展问卷调查。结果柳州市社区居民健康素养总体水平是8.4%,社区居民有关健康的理念和基本知识知晓率为63.6%,健康生活方式与行为率为62.9%,健康技能率为65.5%。结论本市社区居民的健康素养仍属较低水平,需加大健康教育的广度与深度,促进公民健康素养的提高。     

Public Health Insurance Enrollment among Immigrants and Nonimmigrants: Findings from the 2001 California Health Interview Survey

We examine whether adult immigrants in California had the same likelihood of having public health insurance as nonimmigrants with comparable characteristics, using 44,434 non-elderly adult samples of the 2001 California Health Interview Survey public use data. Multinomial logistic regression was used to assess the likelihood of public health insurance relative to private (employment-based or privately purchased) health insurance by generation status, controlling for individual characteristics. The outcome of interest was public health insurance among three health insurance categories: private health insurance, public health insurance, and uninsured. Both first and second generation immigrants were more likely to have public health insurance than were nonimmigrants. However, the difference vanished, when demography, socioeconomic status, health status, employment sector, and English facility were controlled for. The combined effect of lower returns to education and lower employment-based insurance offer rates seems to be the underlying cause of higher prevalence of public health insurance among ethnic minorities.     

Involving Local Health Departments in Community Health Partnerships: Evaluation Results from the Partnership for the Public’s Health Initiative

Improving community health “from the ground up” entails a comprehensive ecological approach, deep involvement of community-based entities, and addressing social determinants of population health status. Although the Centers for Disease Control and Prevention, the Office of the Surgeon General, and other authorities have called for public health to be an “inter-sector” enterprise, few models have surfaced that feature local health departments as a key part of the collaborative model for effecting community-level change. This paper presents evaluation findings and lessons learned from the Partnership for the Public’s Health (PPH), a comprehensive community initiative that featured a central role for local health departments with their community partners. Funded by The California Endowment, PPH provided technical and financial resources to 39 community partnerships in 14 local health department jurisdictions in California to promote community and health department capacity building and community-level policy and systems change designed to produce long-term improvements in population health. The evaluation used multiple data sources to create progress ratings for each partnership in five goal areas related to capacity building, community health improvement programs, and policy and systems change. Overall results were generally positive; in particular, of the 37 partnerships funded continuously throughout the 5 years of the initiative, between 25% and 40% were able to make a high level of progress in each of the Initiative’s five goal areas. Factors associated with partnership success were also identified by local evaluators. These results showed that health departments able to work effectively with community groups had strong, committed leaders who used creative financing mechanisms, inclusive planning processes, organizational changes, and open communication to promote collaboration with the communities they served. Cheadle is with the Department of Health Services, University of Washington, Seattle, WA, USA; Hsu, Pearson, and Beery are with the Center for Community Health and Evaluation, Seattle, WA, USA; Schwartz is with the Kaiser Foundation Health Plan and Hospitals, Oakland, CA, USA; Greenwald is with the School of Policy, Planning, and Development, University of Southern California, Los Angeles, CA, USA; Flores is with the The California Endowment, San Francisco, CA, USA; Casey is with the Partnership for the Public’s Health, Oakland, CA, USA.     

Health insurance and subjective well-being: Evidence from two healthcare reforms in the United States

We study the role of access to health insurance coverage as a determinant of individuals' subjective well-being (SWB) by analyzing large-scale healthcare reforms in the United States. Using data from the Behavioral Risk Factor Surveillance System and Panel Study of Income Dynamics, we find that the 2006 Massachusetts reform and 2014 Affordable Care Act Medicaid expansion improved the overall life satisfaction of Massachusetts residents and low-income adults in Medicaid expansion states, respectively. The results are robust to various sensitivity and falsification tests. Our findings imply that access to health insurance plays an important role in improving SWB. Without considering psychological benefits, the actual benefits of health insurance may be underemphasized.     

上海市嘉定区黄渡社区2型糖尿病患者膳食调查分析

目的对在本中心就诊的2型糖尿病患者膳食状况进行调查分析,为今后的营养治疗工作提供科学依据。方法随机抽取已确诊的2型糖尿病患者220例,采用72小时膳食回顾法,调查之前3天患者的饮食情况,采用《营养之星专家系统》软件评价患者平均每人每日摄入的总热量及三大营养素的摄入情况。结果患者每天蛋白质、脂肪平均实际供能比例均高于推荐的比例,而碳水化合物平均实际供能比例均低于推荐的比例,差异均有统计学意义（P〈0.05）;不同年龄组患者总热量摄入情况比较无统计学差异（P〉0.05）;正常体重组患者每天平均实际摄入的能量低于其每天平均标准能量供给量,而超重肥胖组则高于其每天平均标准能量供给量,两者差异均有统计学意义（P〈0.05）。结论 2型糖尿病患者存在饮食摄入量和饮食结构不合理的情况,亟待加强对糖尿病患者的饮食指导。     

Health insurance reform and retirement: Evidence from the Affordable Care Act

The Affordable Care Act (ACA) has provided millions of Americans with medical insurance but may have led to an increase in retirement among older individuals who are utilizing the newly available coverage options as a substitute for employer‐provided insurance. Using data from the American Community Survey from 2009–2016, this hypothesis is tested by estimating the effect of the premium subsidies and Medicaid expansions of the ACA on retirement transitions for the non‐Medicare eligible cohort of older Americans aged 55–64. Research results indicate a 2% and 8% decrease in labor force participation resulting from the premium subsidies and Medicaid expansions, respectively. Slightly larger estimates are found among a subgroup of adult couples. The study also finds suggestive evidence of crowd‐out of employer‐sponsored insurance by subsidized marketplace plans but finds no such effects from the Medicaid expansions.     

Public Health Emergency Preparedness at the Local Level: Results of a National Survey

Objective. To study the relationship between elements of public health infrastructure and local public health emergency preparedness (PHEP).
Data Sources/Study Setting. National Association of County and City Health Officials 2005 National Profile of Local Health Departments (LHDs).
Study Design. Cross-sectional.
Principal Findings. LHDs serving larger populations are more likely to have staff, capacities, and activities in place for an emergency. Adjusting for population size, the presence of a local board of health and the LHDs' experience in organizing PHEP coalitions were associated with better outcomes.
Conclusions. The results of this study suggest that more research should be conducted to investigate the benefit of merging small health departments into coalitions to overcome the inverse relationship between preparedness and population size of the jurisdiction served by the LHD.     

Examining neighbourhood confounding in a survey: an example using the National Health and Nutrition Examination Survey II

This paper demonstrates a methodology for examining whether neighbourhood stratification lessens the confounding bias of some specific risk-factor/disease associations in analysis of the National Health and Nutrition Examination Survey II (NHANES II). The fortuitous clustering of the sample design of NHANES allows us to estimate risk-factor/disease associations with and without controlling for neighbourhood effects on the same population. We briefly discuss the implications of this methodology for neighbourhood matching in case-control studies.