Children''s Health Insurance Status, Access to and Utilization of Health Services, and Unmet Health Needs in a Rural Alabama School System

PURPOSE: This study examines the relationship between children's health insurance status and utilization of health services, establishment of a medical home, and unmet health needs over a 3-year period (1996-1998) in a rural Alabama K-12 school system. METHODS: As part of a children's health insurance outreach program, questionnaires were administered to parents of 754 children regarding health and health care access. In addition, noninvasive head-to-toe physical assessments of children were conducted on-site at 4 schools. FINDINGS: A relationship between health care utilization and insurance status was observed. Results found that insured children had 1.183 (P < .0115) times the number of medical visits as uninsured children. Among uninsured children, the time since last dental visit was 1.6 (P < .001) times longer than that of insured children. Also, insured children were 5.21 times more likely than uninsured (P < .0001) to report having a medical home. No significant differences between insured and uninsured children were found regarding unmet health needs as measured by referrals made after the children's physical assessments. CONCLUSIONS: Child health coverage is an important determining factor in the ability of families to access and utilize health care services. These findings have implications for populations in similar rural communities across the nation.     

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California

OBJECTIVE: To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees. DATA SOURCES/SETTING: We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey. STUDY DESIGN: We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations. DATA COLLECTION: We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement. FINDINGS: Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable. CONCLUSIONS: While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.     

Mental health and substance abuse parity: a case study of Ohio's state employee program

BACKGROUND: In the United States, insurance benefits for treating alcohol, drug abuse and mental health (ADM) problems have been much more limited than medical care benefits. To change that situation, more than 30 states were considering legislation that requires equal benefits for ADM and medical care ("parity") in the past year. Uncertainty about the cost consequences of such proposed legislation remains a major stumbling block. There has been no information about the actual experience of implementing parity benefits under managed care or the effects on access to care and utilization. AIMS OF THE STUDY: Document the experience of the State of Ohio with adopting full parity for ADM care for its state employee program under managed care. Ohio provides an unusually long time series with seven years of managed behavioral health benefits, which allows us to study inflationary trends in a plan with unlimited ADM benefits. METHODS: Primarily a case study, we describe the implementation of the program and track utilization, and costs of ADM care from 1989 to 1997. We use a variety of administrative and claims data and reports provided by United Behavioral Health and the state of Ohio. The analysis of the utilization and cost effect of parity and managed care is pre-post, with a multiyear follow-up period. RESULTS: The switch from unmanaged indemnity care to managed carve-out care was followed by a 75% drop in inpatient days and a 40% drop in outpatient visits per 1000 members, despite the simultaneous increase in benefits. The subsequent years saw a continuous decline in inpatient days and an increased use of intermediate services, such as residential care and intensive outpatient care. The number of outpatient visits stabilized in the range of 500-550 visits per 1000. There was no indication that costs started to increase during the study period; instead, costs continued to decline. A somewhat different picture emerges when comparing utilization under HMOs with utilization under a carve-out with expanded benefits. In that case, the expansion of benefits led to a significant jump in outpatient utilization and intermediate services, while there was a small decrease in inpatient days. Insurance payments in 1996/1997 were almost identical to the estimated costs under HMOs in 1993. CONCLUSIONS: In contrast to the emerging inflation anxiety regarding overall health care costs, managed care can provide long-run cost containment for ADM care even when patient copayments are reduced and coverage limits are lifted. This may differentiate ADM care from medical care and reasons for this difference include the state of management techniques (more advanced for ADM care), complexity of treatments (much higher technology utilization in medical care) and demographic factors (medical, but not behavioral health, costs increase as the population ages). IMPLICATIONS FOR HEALTH POLICY: The experience of the state of Ohio demonstrates that parity level benefits for ADM care are affordable under managed care. It suggests that the concerns about costs that have stymied ADM policy proposals are unfounded, as long as one is willing to accept managed care. IMPLICATIONS FOR RESEARCH: The continuing decline in costs raises concerns that levels of care may become insufficient. While concerns about costs being too high dominate the policy hurdle for parity legislation at this moment, the next step in research is to address quality of care or health outcomes, areas about which even less is known than about costs.     

Lessons for coverage expansion: a Virginia primary care program for the uninsured reduced utilization and cut costs

The Affordable Care Act will expand health insurance coverage for an estimated thirty-two million uninsured Americans. Increased access to care is intended to reduce the unnecessary use of services such as emergency department visits and to achieve substantial cost savings. However, there is little evidence for such claims. To determine how the uninsured might respond once coverage becomes available, we studied uninsured low-income adults enrolled in a community-based primary care program at Virginia Commonwealth University Medical Center. For people continuously enrolled in the program, emergency department visits and inpatient admissions declined, while primary care visits increased during the study period. Inpatient costs fell each year for this group. Over three years of enrollment, average total costs per year per enrollee fell from $8,899 to $4,569--a savings of almost 50 percent. We conclude that previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage but that it may take several years of coverage for substantive health care savings to occur.     

Mental health parity: what are the gaps in coverage?

BACKGROUND: Mental health benefits in private health insurance plans in the United States are typically less generous than benefits for physical health care services, driving reform efforts to achieve parity in coverage. While there is growing evidence about the effects such legislation would have on the utilization and cost of mental health services, less is known about the impact parity would have on reducing the risk of large out-of-pocket expenses that families would face in the event of mental illness. AIMS OF THE STUDY: We seek to understand the impact that mental health parity would have on the out-of-pocket burden that families would face in the event of mental illness. We focus in particular on variations in coverage across the privately insured population. METHODS: We compare out-of-pocket spending for hypothetical episodes of mental health treatment, first under current insurance coverage in the United States and then under a reform policy of full mental health parity. We exploit detailed informtion on actual health plan benefits using a nationally-representative sample of the privately insured population under age 65 from the 1987 National Medical Expenditure Survey (NMES) that has been carefully aged and reweighted to represent 1995 population and benefit characteristics. RESULTS: Our results show that existing benefits of the U.S. privately insured population under age 65 leave most people at risk of high out-of-pocket costs in the event of a serious mental illness. Moreover, the generosity of existing mental health benefits varies widely across subgroups, particularly across firm size. We find significantly lower out-of-pocket costs when simulating full parity coverage. However, our results show those with less generous mental health coverage tend to have less generous physical health coverage, as well. CONCLUSIONS: Parity would substantially increase generosity of mental health coverage for most of the privately insured population. The wide variation in the generosity of existing mental health benefits suggests that there are likely to be differential impacts from a parity mandate. Those with limited physical health coverage would still be at significant financial risk for catastrophic mental illness.     

Health risk influence on medical care costs and utilization among 2,898 municipal employees

Introduction: Although worksite health promotion programs are credited with stabilizing medical benefits costs, research is needed to characterize the medical costs of cohorts with selected health risk factors. The purpose of this study was to compare medical cost outcomes in City of Birmingham, Alabama, employees who differ on selected health risk factors.Methods: Health risk appraisal and medical claims cost data were examined in 2,898 employees participating in health screening during 1992 and 1993. Probit analysis was employed to test the null hypotheses that there are no differences in (1) probability of medical service utilization and (2) probability of medical service cost quartile (high, moderate, and low) between groups characterized by risks. Age, gender, race, education, marital status, and diabetes were included as covariates in each model examined. In addition, smoking habits was included as a covariate in models involving risk taking behavior and psychosocial risk.Results: Significant differences in medical care utilization and costs were found between risk groups based on psychosocial risk, cardiovascular disease risk, and total risk. No association was found between risk-taking behavior and utilization and costs.Conclusion. Subjects reporting psychosocial, cardiovascular disease, and total risk factors were more likely to use medical services and to be in the high or high/moderate cost categories.     

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.     

基本医保参保人门诊医疗服务利用、费用及风险分析

目的：分析45岁以上人群门诊服务利用、费用和风险。方法：基于CHARLS2018年数据,分别进行单因素分析和多元logit回归。结果：门诊服务利用率明显低于自行购药,门诊费用和自行购药费用月均1 000元以上组占比最高,门诊和购药费用获得医保报销的比例明显低于住院,报销比例亦是如此。门诊保障水平对门诊费用利用影响有统计学意义;门诊服务利用和自行购药都是引致灾难性卫生支出的重要影响因素;随着慢病患者患病种数的增加,未住院患者发生灾难性卫生支出的风险增加。建议：完善基本医保门诊报销政策,引导患者合理利用医疗服务,提高基金支出效率;重新认识门诊费用,重构医保待遇保障组合;提高慢病患者的门诊保障水平,减轻慢病患者门诊费用风险。     

Children of working low-income families in California: does parental work benefit children's insurance status,access, and utilization of primary health care?

OBJECTIVE: To examine financial and nonfinancial access to care and utilization of primary health care services among children of working low-income families earning below 200 percent of the federal poverty level in California, and to compare them to children in nonworking low-income families and in families earning over 200 percent of poverty. DATA SOURCES/STUDY SETTING: The 1994 National Health Interview survey weighted to reflect population estimates for California. STUDY DESIGN: This cross-sectional study of 3,831 children under age 19 focuses on financial access, that is, the prevalence and continuity of health insurance coverage; structural access, including the presence of a usual source of care, the predominant care source, its responsiveness to patient's needs, and any indications of delayed or missed care; and utilization of health care measured by the presence of an outpatient doctor's visit and the mean number of visits relative to child health status. DATA COLLECTION: The study uses secondary analysis. FINDINGS: Compared to children of nonworking low-income parents and to nonpoor children, children of working low-income parents were more likely to be uninsured (32.1 percent versus 15.6 percent and 10.3 percent, p = .0001) and to experience disruptions in insurance coverage (p = .0009). These differences persisted after controlling for other covariates in multivariate analyses. Children of working low-income parents did not differ significantly from children of nonworking low-income parents on measures of structural access or utilization, after adjusting for other covariates. However, they differed significantly from nonpoor children on structural access and utilization, and these differences mostly persisted after adjusting for other covariates (odds ratios from 1.5 to 2.9). Similar patterns were observed when children of full-time, year-round working parents with low earnings were compared with the two reference populations. CONCLUSION: Children in working low-income families in California have some of the worst access problems. Even full attachment to the workforce does not guarantee health insurance benefits, access to care, or improved health care use for children of low-income parents. These children are not better off than other low-income children of nonworking parents and are much worse off than nonpoor children. Expansion of health insurance coverage through Healthy Families and Medi-Cal, and attention to nonfinancial barriers to care for working low-income families may help to reduce these disparities.     

Preventive dental care and unmet dental needs among low-income children

OBJECTIVES: We examined the ways in which levels of preventive dental care and unmet dental needs varied among subgroups of low-income children. METHODS: Data were drawn from the 2002 National Survey of America's Families. We conducted bivariate and multivariate analyses, including logistic regression analyses, to assess relationships between socioeconomic, demographic, and health factors and receipt of preventive dental care and unmet dental needs. RESULTS: More than half of low-income children without health insurance had no preventive dental care visits. Levels of unmet dental needs among low-income children who had private health insurance coverage but no dental benefits were similar to those among uninsured children. Children of parents whose mental health was rated as poor were twice as likely to have unmet dental needs as other children. CONCLUSIONS: Additional progress toward improving the dental health of low-income children depends on identifying and responding to factors limiting both the demand for and the supply of dental services. In particular, it appears that expanding access to dental benefits is key to improving the oral health of this population.     

Does the Universal Health Insurance Program Affect Urban‐Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

Purpose: To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban‐rural inequality in health service utilization among the elderly. Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference‐in‐differences model was employed and estimated by the random‐effect probit method. Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents. Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.     

2015-2019年广西城乡居民医疗保险卫生服务利用与医保待遇水平分析

目的:对2015-2019年广西城乡居民医疗保险卫生服务利用与医保待遇水平进行分析,探索其存在的问题并提出相应建议。方法:从不同主体的普通门急诊、门诊大病、住院的次均就诊费用及平均住院日和相对应的统筹支付占比等指标来描述分析广西2015-2019年城乡居民医疗保险卫生服务利用和医保待遇水平情况;结果:普通门急诊、门诊大病和住院的次均费用的年均增长率变化区间分别为-3.49%~8.38%、2.93%~31.41%和-3.36%~10.42%;其中,总体门诊大病次均就诊费用、大学生、学生儿童、三级医院和异地就医门诊大病次均就诊费用年均增长率分别为9.39%、31.41%、13.39%、13.01%和23.7%;平均住院日年均降幅在4.5%-10.26%之间。总统筹支付占比在37.82%~59.44%之间。结论:门诊大病费用增长较快;平均住院床日有效缩短;保障待遇水平应加强费用控制,减少患者就医中的不合理开支。     

Who will provide preventive services? The changing relationships between medical care systems and public health agencies in health care reform.

Health care reform in the United States will likely attempt to expand the health insurance coverage to uninsured groups, control costs, enhance quality, and expand access to care. Preventive services will be assigned to the medical care system, while new roles and responsibilities will be defined for public health agencies. The clinical preventive services likely required are examined in a population of 44,565 persons residing in Otsego County, New York. Expansion of preventive services to Medicaid requests and the uninsured will require considerable resource expenditure to correct the current deficit in preventive services received by these groups. Moreover, the uninsured and Medicaid recipients have high levels of risk behaviors, identifying a need for health education services effective to that population subgroup. The transfer of responsibilities for clinical preventive services to the medical care system may free up resources for public health agencies to focus on other initiatives such as disease surveillance, health education, and quality assurance. New interrelationships, some cooperative and some adversarial, are likely to emerge, due to a closer working relationship between the medical care system and public health agencies than previously seen in American health care.     

Rural–urban disparities in the utilization of mental health inpatient services in China: the role of health insurance

Reducing rural–urban disparities in health and health care has been a key policy goal for the Chinese government. With mental health becoming an increasingly significant public health issue in China, empirical evidence of disparities in the use of mental health services can guide steps to reduce them. We conducted this study to inform China’s on-going health-care reform through examining how health insurance might reduce rural–urban disparities in the utilization of mental health inpatient services in China. This retrospective study used 10 years (2005–2014) of hospital electronic health records from the Shandong Center for Mental Health and the DaiZhuang Psychiatric Hospital, two major psychiatric hospitals in Shandong Province. Health insurance was measured using types of health insurance and the actual reimbursement ratio (RR). Utilization of mental health inpatient services was measured by hospitalization cost, length of stay (LOS), and frequency of hospitalization. We examined rural–urban disparities in the use of mental health services, as well as the role of health insurance in reducing such disparities. Hospitalization costs, LOS, and frequency of hospitalization were all found to be lower among rural than among urban inpatients. Having health insurance and benefiting from a relatively high RR were found to be significantly associated with a greater utilization of inpatient services, among both urban and rural residents. In addition, an increase in the RR was found to be significantly associated with an increase in the use of mental health services among rural patients. Consistent with the existing literature, our study suggests that increasing insurance schemes’ reimbursement levels could lead to substantial increases in the use of mental health inpatient services among rural patients, and a reduction in rural–urban disparities in service utilization. In order to promote mental health care and reduce rural–urban disparities in its utilization in China, improving rural health insurance coverage (e.g., reducing the coinsurance rate) would be a powerful policy instrument.     

Losing and acquiring health insurance: consequences for health care

Data from a sample of 5530 Nebraska adults under age 65 are used to analyze the independent correlates of four different insurance statuses: insured 12 consecutive months, uninsured 12 consecutive months, insured at the end of a 12 month period, but not throughout, and uninsured at the end of a 12 month period, but not throughout. The effects of insurance status on utilization of health care services when perceived to be needed are assessed, controlling for demographic explanations. The results show that uninsurance status, whether long-lasting or recent, indicates lower utilization than being insured. Policies designed to expand the number of persons with insurance, especially those linked to practices of insurers, are predicted to have little impact since the underlying causes of uninsurance are related to household income. Lower use of health care services among the uninsured is thought to present financial problems to providers, since the uninsured who do seek care are more likely to need more services (without paying). Problems of higher cost to treat these individuals also present problems for public policies that in effect create subsidies to expand the number of insured. Finally, this study indicates that incremental policy approaches may not deal adequately with the fundamental problems that result in increases in the number of uninsured Americans and caring for their health care needs.     

Children Who Are Medically Fragile in North Carolina: Using Medicaid Data to Estimate Prevalence and Medical Care Costs in 2004

Objectives: The purpose of this paper is to demonstrate a method of using medical insurance paid claims and enrollment data to estimate the prevalence of selected health conditions in a population and to profile associated medical care costs. The examples presented here use North Carolina Medicaid data to produce estimates for children ages 0–19 who are medically fragile. These children with serious health conditions are a small subset of all children with special health care needs. Methods: The children who are medically fragile were identified through selected procedure and durable medical equipment codes. We profiled the expenditures for all medical services provided to these children during 2004. Results: 1,914 children ages 0–19 enrolled in Medicaid were identified as medically fragile (0.22 percent). The amount paid by Medicaid for these children during 2004 for all medical services was $133.8 million, or $69,906 per child. By comparison, the average expenditure by Medicaid during 2004 for a randomly selected group of children receiving well-child care visits was $3,181 per child. The $133.8 million of Medicaid expenditures for the children who are medically fragile represents 6.8 percent of the nearly $2 billion spent by Medicaid in 2004 for all medical services for all children ages 0–19. Conclusions: This study presents a standard methodology to identify children with specific health conditions and describe their medical care costs. Our example uses Medicaid claims and enrollment data to measure prevalence and costs among children who are medically fragile. This approach could be replicated for other health care payer data bases and also in other geographic areas.     

Assessing an intensive school-based assistance program to enroll uninsured children

Children eligible but not enrolled in subsidized health insurance programs, such as Medicaid and S-CHIP, received considerable outreach activity in recent years. Schools in low-income and middle-income communities often are cited as excellent places to find and reach parents. This study assessed the cost and effectiveness of contacting parents through schools, educating them about health insurance programs and preventive care, and assisting them with insurance applications. The accumulative cost per enrolled child was $75, and schools were able to locate and assist large numbers of uninsured children who had failed other outreach methods. School-based application assistance and parent education succeeded in improving child access to care and utilization of services.     

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.