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We examine the prevalence and correlates of health insurance status among low-income fathers, a group not previously studied in this context. In a sample of 1,653 low-income fathers from a national urban birth cohort study, 29% had private, 14% had public, and 58% had no insurance. Privately insured fathers had greater levels of human capital than did publicly insured fathers; the latter more closely resembled uninsured fathers than they did privately insured fathers. Multinomial logistic regression analysis indicates that being older, being employed, being married, and having a job offering health insurance all increase the likelihood of having private (vs. no) insurance, and that being disabled and married to or cohabiting with the child’s mother increase the likelihood of having public (vs. no) insurance. Public policy should focus on increasing access to health insurance among low-income men, which may improve their health, productivity, and ability to support themselves and their children.

Objective

The aim of this study was to develop a policy characterisation process based on measuring shifts in use of private health insurance (PHI) immediately following implementation of changes in federal health care policy.

Method

Population-based hospital morbidity data from 1980 to 2001 were used to produce trend lines in the annual proportions of public, privately insured and privately uninsured hospital separations in age-stratified subgroups. A policy characterisation model was developed using visual and statistical assessment of the trend lines associated with changes in federal health care policy.

Results

Of eight changes in federal health care policy, two (introduction of Medicare and Lifetime Health Cover) were directly associated with major changes in the trend lines; however, minor changes in trends were associated with several of the other federal policies. Three types of policy effects were characterised by our model: direction change, magnitude change and inhibition. Results from our model suggest that a policy of Lifetime Health Cover, with a sanction for late adoption of PHI, was immediately successful in changing the private: public mix. The desired effect of the 30% rebate was immediate only in the oldest age group (70+ years), however, introduction of the lifetime health cover and limitations in the model restricted the ability to determine whether or if the rebate had a delayed effect at younger ages.

Conclusion

An outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy.

Background

Private health insurance has been a major focus of Commonwealth Government health policy for the last decade. Over this period, the Howard government introduced a number of policy changes which impacted on the take up of private health insurance. The most expensive of these was the introduction of the private health insurance rebate in 1997, which had an estimated cost of $3 billion per annum.

Methods

This article uses information on the geographic distribution of the population with private health insurance cover to identify associations between rates of private health insurance cover and socioeconomic status. The geographic analysis is repeated with survey data on expenditure on private health insurance, to provide an estimate of the rebate flowing to different socioeconomic groups.

Results

The analysis highlights the strong association between high rates of private health insurance cover and high socioeconomic status and shows the substantial transfer of funds, under the private health insurance rebate, to those living in areas of highest socioeconomic status, compared with those in areas of lower socioeconomic status, and in particular those in the most disadvantaged areas. The article also provides estimates of private health insurance cover by federal electorate, emphasising the substantial gaps in cover between Liberal Party and Australian Labor Party seats.

Conclusion

The article concludes by discussing implications of the uneven distribution of private health insurance cover across Australia for policy formation. In particular, the study shows that the prevalence of private health insurance is unevenly distributed across Australia, with marked differences in prevalence in rural and urban areas, and substantial differences by socioeconomic status. Policy formation needs to take this into account. Evaluating the potential impact of changes in private health insurance requires more nuanced consideration than has been implied in the rhetoric about private health insurance over the last decade.

Methods: A prospective cohort study was carried out on 81 patients with RA who completed four consecutive three month cost diaries. The SF-36, HAQ, and social impact at baseline and one year follow up were also assessed.

Results: Women reported worse SF-36 physical function and HAQ scores than men and received more assistance from family and friends. Women spent more on non-prescription medication and devices to assist them than men. Older patients had higher expenditure on visits to health professionals, whereas younger patients spent more on prescription medication and tests. Pension status and membership of private health insurance schemes were important determinants in these differences in expenditure.

Conclusion: Costs increased with duration of disease, those with private health insurance had greater out of pocket costs (excluding membership fees), and those with pension support had fewer costs. Women were more affected by RA than men in health status, social impact, and out of pocket costs.

This article examines the factors that affect Medicare beneficiaries' choices in the supplemental health insurance market. Data include detailed survey information as well as copies of the health insurance policies owned by a sample of approximately 2,500 Medicare beneficiaries in six states during 1982. Logit analysis is employed to analyze the determinants of four dependent variables: whether a person owns (1) one or more private supplemental insurance policies, (2) two or more policies, (3) at least one policy that we define as "effective," and (4) a policy we define to be "less effective." Those who are better off from a socioeconomic standpoint appear to be making more effective choices in the supplemental health insurance market. However, there does not appear to be a relationship between consumer ignorance or vulnerability and the purchase of multiple supplemental insurance policies. Study results imply an important role for public policy in helping to provide the information necessary to ensure that the most vulnerable beneficiaries make insurance choices that are in their best interest.

Introduction: Healthy People 2020 set a goal to increase the proportion of children who receive the recommended doses of Diphtheria Tetanus and Pertussis, polio, measles mumps and rubella, Haemophilus influenzae type b, hepatitis B, varicella and pneumococcal conjugate vaccines to 80% from the 2009 baseline rate of 69%. The purpose of this study is to compare the recommended immunization rates for low-income children insured through publicly funded health insurance (PFI) to the rates for children with private health insurance (PHI) in a suburban medical office.

Methods: The immunization rates and health access measures of 109 children ages 24 to 48 months who had PFI were compared with 300 children of the same age with PHI in the same medical practice.

Results: Overall immunization rates for the study population were very high and exceeded the Healthy People 2020 goals for full immunization. Children with PFI had lower rates of immunization and fluoride prescriptions; however the differences were only significant in the cohort of children age two years. By three years of age, the immunization rates and the fluoride prescription rates were similar. There were no significant differences in health outcomes for Spanish-speaking compared with English-speaking children.

Discussion: Barriers to successful immunization practices and strategies to overcome those barriers are discussed.

Conclusion: The successful immunization practices and secondary outcomes in this study are a reflection of the integrated care model in this practice that facilitates comprehensive, coordinated, and accessible care for patients and allows physicians and support staff to practice culturally sensitive and compassionate care—the definition of a medical home.

Background

Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments.

Methods

The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990–2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments.

Results

These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems’ performance with regards to health insurance access and equity.

Conclusion

This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.

Background

Lack of health insurance is a key barrier to accessing care for chronic conditions and cancer screening. We examined the influence of insurance type (private, public, none) on survivor-focused and general preventive health care in adult survivors of childhood cancer.

Methods

The Childhood Cancer Survivor Study is a retrospective cohort study of childhood cancer survivors diagnosed between 1970–1986. Among 8425 adult survivors, the Relative Risk (RR), 95% confidence interval (CI) of receiving survivor-focused and general preventive health care were estimated for uninsured (n=1390) and publicly insured (n=640), comparing to privately insured (n=6395).

Results

Uninsured survivors were less likely than privately insured to report a cancer-related (adjusted RR=0.83, 95% CI, 0.75–0.91) or a cancer center visit (adjusted RR=0.83, 95% CI, 0.71–0.98). Uninsured survivors had lower levels of utilization in all measures of care in comparison with privately insured. In contrast, publicly insured survivors were more likely to report a cancer-related (adjusted RR=1.22, 95% CI, 1.11–1.35) or a cancer center visit (adjusted RR=1.41, 95% CI, 1.18–1.70) than privately insured. While having a similar utilization level of general health examinations, publicly insured survivors were less likely to report Papanicolaou smear or dental examinations.

Conclusion

Among this large, socioeconomically diverse cohort, publicly insured survivors utilize survivor-focused health care at rates at least as high as survivors with private insurance. Uninsured survivors have lower utilization to both survivor-focused and general preventive health care.

Introduction

Socio-demographic and clinical factors associated with increased sepsis risk, including older age, non-white race and specific co-morbidities, are more common among patients with Medicare or Medicaid or no health insurance. We hypothesized that patients with Medicare and/or Medicaid or without health insurance have a higher risk of sepsis-associated hospitalization or sepsis-associated death than those with private health insurance.

Methods

We performed a retrospective cohort study of records from the 2003 Nationwide Inpatient Sample. We stratified the study cohort by Medicare age-qualification (18 to 64 and 65+ years old). We examined the association between insurance category and sepsis diagnosis and death among admissions involving sepsis. We used validated diagnostic codes to determine the presence of sepsis, co-morbidities and organ dysfunction and to provide risk-adjustment.

Results

Among patients 18 to 64 years old, those with Medicaid (adjusted odds ratio (AOR) 1.50), Medicare (AOR 1.96), Medicaid + Medicare (AOR 2.22) and the uninsured (AOR 1.18) had significantly higher risk-adjusted odds of a sepsis-associated admission than those with private insurance (all P < 0.0001). Those with Medicaid (AOR 1.17, P < 0.001) and those without insurance (AOR 1.45, P < 0.001) also had significantly higher adjusted odds of sepsis-associated hospital mortality than those with private insurance. Among those 65+ years old, those with Medicaid (AOR 1.43), Medicare alone (AOR 1.13) or Medicaid + Medicare (AOR 1.62) had significantly higher risk-adjusted odds of sepsis-associated admission than those with private insurance and Medicare (all P < 0.0001). Among sepsis patients 65+, uninsured patients had significantly higher risk-adjusted odds (AOR 1.45, P = 0.0048) and those with Medicare alone had significantly lower risk-adjusted odds (AOR 0.92, P = 0.0072) of hospital mortality than those with private insurance and Medicare. Lack of health insurance remained associated with sepsis-associated mortality after stratification of hospitals into quartiles based on rates of sepsis-associated admissions or mortality in both age strata.

Conclusions

Risks of sepsis-associated hospitalization and sepsis-associated death vary by insurance. These increased risks were not fully explained by the available socio-demographic factors, co-morbidities or hospital rates of sepsis-related admissions or deaths.

BACKGROUND

Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance.

OBJECTIVE

To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare.

DESIGN

Prospective cohort study.

PARTICIPANTS

Participants (N = 3,419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview.

MEASUREMENTS

We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t−2 to t0) and the following 2 years (t0 to t2).

RESULTS

Between the interview before age 65 (t−2) and the first interview after reaching age 65 (t0), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t0 to t2), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare.

CONCLUSIONS

Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.

Objectives

To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.

Design

Qualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.

Setting

Santiago, Chile.

Participants

Qualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.

Main outcome measures

Rates of caesarean section in different types of institutions; consultants' views on private practice; work patterns in private practice; women's reasons for choosing private care; women's preferences on method of delivery.

Results

Private health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.

Conclusions

Policies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.

Abstract

Objectives

To determine if (1) birth outcomes among women on Medicaid differ significantly from outcomes of those with private insurance, after controlling for known risk factors, and (2) enhanced prenatal care influences care use and birth outcomes.

Methods

This is a review of studies published between 1989 and 2009 that examined birth outcomes (1) between women on Medicaid and those with private insurance and (2) among Medicaid enrollees who received comprehensive prenatal care.

Results

When corrected for risk variables, birth outcomes are not different between private insurance and Medicaid patients. The impact of comprehensive prenatal care programs on birth outcomes varies across states and regions.

Conclusions

There is a need for critical evaluation of comprehensive programs in a regional and state context to determine opportunities for improvement.

Background

Proposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients.

Methods

Data from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics.

Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs) and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios.

Results

Medicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone.

Conclusion

Supplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.

Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.

Background

Publicly insured women usually have a different demographic background to privately insured women, which is related to poor neonatal outcomes after birth. Given the difference in nature and risk of preterm versus term births, it would be important to compare adverse neonatal outcomes after preterm birth between these groups of women after eliminating the demographic differences between the groups.

Methods

The study population included 3085 publicly insured and 3380 privately insured, singleton, preterm deliveries (32–36 weeks gestation) from Western Australia during 1998–2008. From the study population, 1016 publicly insured women were matched with 1016 privately insured women according to the propensity score of maternal demographic characteristics and pre-existing medical conditions. Neonatal outcomes were compared in the propensity score matched cohorts using conditional log-binomial regression, adjusted for antenatal risk factors. Outcomes included Apgar scores less than 7 at five minutes after birth, time until establishment of unassisted breathing (>1 minute), neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit.

Results

Compared with infants of privately insured women, infants of publicly insured women were more likely to receive a low Apgar score (ARR = 2.63, 95% CI = 1.06-6.52) and take longer to establish unassisted breathing (ARR = 1.61, 95% CI = 1.25-2.07), yet, they were less likely to be admitted to a special care unit (ARR = 0.84, 95% CI = 0.80-0.87). No significant differences were evident in neonatal resuscitation between the groups (ARR = 1.20, 95% CI = 0.54-2.67).

Conclusions

The underlying reasons for the lower rate of special care admissions in infants of publicly insured women compared with privately insured women despite the higher rate of low Apgar scores is yet to be determined. Future research is warranted in order to clarify the meaning of our findings for future obstetric care and whether more equitable use of paediatric services should be recommended.

Introduction

During the first winter of exposure, the H1N1 2009 influenza virus placed considerable strain on intensive care unit (ICU) services in Australia and New Zealand (ANZ). We assessed the impact of the H1N1 2009 influenza virus on ICU services during the second (2010) winter, following the implementation of vaccination.

Methods

A prospective, cohort study was conducted in all ANZ ICUs during the southern hemisphere winter of 2010. Data on demographic and clinical characteristics, including vaccination status and outcomes, were collected. The characteristics of patients admitted during the 2010 and 2009 seasons were compared.

Results

From 1 June to 15 October 2010, there were 315 patients with confirmed influenza A, of whom 283 patients (90%) had H1N1 2009 (10.6 cases per million inhabitants; 95% confidence interval (CI), 9.4 to 11.9) which was an observed incidence of 33% of that in 2009 (P < 0.001). The maximum daily ICU occupancy was 2.4 beds (95% CI, 1.8 to 3) per million inhabitants in 2010 compared with 7.5 (95% CI, 6.5 to 8.6) in 2009, (P < 0.001). The onset of the epidemic in 2010 was delayed by five weeks compared with 2009. The clinical characteristics were similar in 2010 and 2009 with no difference in the age distribution, proportion of patients treated with mechanical ventilation, duration of ICU admission, or hospital mortality. Unlike 2009 the incidence of critical illness was significantly greater in New Zealand (18.8 cases per million inhabitants compared with 9 in Australia, P < 0.001). Of 170 patients with known vaccination status, 26 (15.3%) had been vaccinated against H1N1 2009.

Conclusions

During the 2010 ANZ winter, the impact of H1N1 2009 on ICU services was still appreciable in Australia and substantial in New Zealand. Vaccination failure occurred.

AIMS—To analyse inequalities by social class in children's access to and utilisation of health services in Catalonia (Spain), private health insurance coverage, and certain aspects of the quality of care received.
DESIGN—Cross sectional study using data from the 1994 Catalan Health Interview Survey.
SETTING—Child population of Catalonia.
PARTICIPANTS—A representative sample of non-institutionalised children younger than 15 years (n = 2433).
MAIN OUTCOME MEASURES—Health services utilisation, perceived health, type of health insurance (only National Health System (NHS) or both NHS and private health insurance), and social class.
RESULTS—No inequalities by social class were found for the utilisation of health care services provided by the NHS among children in most need. Double health care coverage does not influence the social pattern of visits. Nevertheless, social inequalities still remain in the use of those health services provided only partially by the NHS (dentist) and when characteristics of the last consultation are taken into account. That is, subjects who paid for a private service waited an average of 14.8 minutes less than those whose visit was paid for by the NHS only.
CONCLUSION—Equitable access and use of medical care services in relation to need, regardless of the type of insurance and social class of their children and families, has been achieved in this region of Spain; differences by social class remain for those services incompletely covered by national health insurance and aspects of the quality of care provided.



Background

The health insurance system in Taiwan is comprised of public health insurance and private health insurance. The public health insurance, called “universal national health insurance” (NHI), was first established in 1995 and amended in 2011. The goal of this study is to provide an updated description of several important aspects of health insurance in Taiwan. Of special interest are household insurance coverage, medical expenditures (both gross and out-of-pocket), and coping strategies.

Methods

Data was collected via a phone call survey conducted in August and September of 2011. A household was the unit for survey and data analysis. A total of 2,424 households covering all major counties and cities in Taiwan were surveyed.

Results

The survey revealed that households with smaller sizes and higher incomes were more likely to have higher coverage of public and private health insurance. In addition, households with the presence of chronic diseases were more likely to have both types of insurance. Analysis of both gross and out-of-pocket medical expenditure was conducted. It was suggested that health insurance could not fully remove the financial burden caused by illness. The presence of chronic disease and inpatient treatment were significantly associated with higher gross and out-of-pocket medical expenditure. In addition, the presence of inpatient treatment was significantly associated with extremely high medical expenditure. Regional differences were also observed, with households in the northern, central, and southern regions having less gross medical expenditures than those on the offshore islands. Households with the presence of inpatient treatment were more likely to cope with medical expenditure using means other than salaries.

Conclusion

Despite the considerable achievements of the health insurance system in Taiwan, there is still room for improvement. This study investigated coverage, cost, and coping strategies and may be informative to stakeholders of both basic and commercial health insurance.

Objective

To create a consistent time series to understand coverage trends by harmonizing 20 years of insurance coverage estimates from the Current Population Survey (CPS) that are an available public resource.

Data Source

1990–2009 CPS Annual Social and Economic Supplement data.

Study Design

CPS data are enhanced to account for methodological and conceptual changes in health insurance measurement and population control totals.

Principal Findings

The enhancements to the CPS result in an approximately 1 percent reduction in uninsurance rates. Reductions vary over time and by age group. Changes over the last two decades differ slightly using the two data sources. For example, the enhanced data show a greater erosion of private coverage.

Conclusion

The enhanced data provide the most consistent measure of health insurance coverage over the past two decades.

BACKGROUND

In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans' ability to afford care.

OBJECTIVES

To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers.

RESEARCH DESIGN

Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.

PARTICIPANTS

U.S. adults age 18 and older (N=6,722).

MEASURES

Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan.

RESULTS

The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost.

CONCLUSIONS

Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.

Objective

Since 1996, Washington State law has required private health insurance to cover licensed CAM providers. This study evaluated how insured people used CAM providers and what role this played in health care utilization and expenditures.

Study Design

Cross sectional analysis of calendar year 2002 insurance enrollees from Western Washington State.

Methods

Analysis of insurance demographic data, claims files, benefit information, diagnoses, CAM and conventional provider utilization, and health care expenditures for three large health insurance companies.

Results

Among over 600,000 enrollees, 13.7% made CAM claims. This included 1.6% of enrollees with claims for naturopathy, 1.3% acupuncture, 2.4% massage and 10.9% chiropractic. Patients enrolled in Preferred Provider Organizations and Point of Service products were significantly more likely to use CAM than those with Health Maintenance Organization coverage. CAM use was greater in women and people between 31 and 50 years of age. Chiropractic was more frequent in less populous counties. CAM provider visits usually focused on musculoskeletal complaints, except for naturopathic physicians who treated a broader array of problems. Median per visit expenditures for CAM care were $39.00 compared to $74.40 for conventional outpatient care. Total expenditures per enrollee were $2,589 of which $75 (2.9%) was spent on CAM.

Conclusions

The number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest. Because the long term trajectory of CAM cost under third party payment is unknown, utilization of these services should be followed.

OBJECTIVES: To show how health insurance (privately and publicly insured, insured and uninsured) relates to vaccination coverage in children 19-35 months old, and how this can be used to better target public health interventions. METHODS: The National Health Interview Survey (NHIS) gathers information on the health and health care of the U.S. non-institutionalized population through household interviews. The authors combined immunization and health insurance supplements from the 1993 through 1996 NHIS, and classified children 19-35 months old by their immunization and insurance status. Results were compared using both bivariate and multivariate analyses, and the backwards stepwise selection method was used to build multivariate logistic regression models. RESULTS: Uninsured children tended to have lower vaccination coverage than those who had insurance, either private or public. Among those with insurance, publicly insured children had lower vaccination coverage than privately insured children. Backwards stepwise regression retained insurance status, metropolitan statistical area, and education of responsible adult family member as major predictors of immunization. Factors considered but not retained in the final model included child race/ethnicity, family poverty index, and region of country. CONCLUSIONS: Insurance status was a critical predictor of vaccination coverage for children ages 19-35 months. After controlling for confounders, the uninsured were about 24% less likely to receive all recommended shots than the insured and, among the insured, those with public insurance were about 24% less likely to receive all recommended vaccines than those with private insurance.

Background

Equitable financing is a key objective of health care systems. Its importance is evidenced in policy documents, policy statements, the work of health economists and policy analysts. The conventional categorisations of finance sources for health care are taxation, social health insurance, private health insurance and out-of-pocket payments. There are nonetheless increasing variations in the finance sources used to fund health care. An understanding of the equity implications would help policy makers in achieving equitable financing.

Objective

The primary purpose of this paper was to comprehensively assess the equity of health care financing in Malaysia, which represents a new country context for the quantitative techniques used. The paper evaluated each of the five financing sources (direct taxes, indirect taxes, contributions to Employee Provident Fund and Social Security Organization, private insurance and out-of-pocket payments) independently, and subsequently by combined the financing sources to evaluate the whole financing system.

Methods

Cross-sectional analyses were performed on the Household Expenditure Survey Malaysia 1998/99, using Stata statistical software package. In order to assess inequality, progressivity of each finance sources and the whole financing system was measured by Kakwani's progressivity index.

Results

Results showed that Malaysia's predominantly tax-financed system was slightly progressive with a Kakwani's progressivity index of 0.186. The net progressive effect was produced by four progressive finance sources (in the decreasing order of direct taxes, private insurance premiums, out-of-pocket payments, contributions to EPF and SOCSO) and a regressive finance source (indirect taxes).

Conclusion

Malaysia's two tier health system, of a heavily subsidised public sector and a user charged private sector, has produced a progressive health financing system. The case of Malaysia exemplifies that policy makers can gain an in depth understanding of the equity impact, in order to help shape health financing strategies for the nation.

Objective

To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources.

Data Source

Expenditures for health care–using men in Medical Expenditure Panel Surveys from 1996 through 2004.

Study Design

Retrospective, cross-sectional analysis.

Data Collection/Extraction Methods

Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA).

Results

VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance.

Conclusions

VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.

Objective

To examine the effect of price on the demand for health insurance by early retirees between the ages of 55 and 64.

Data Source

Administrative health plan enrollment data from a medium-sized U.S. employer.

Study Design

The analysis takes advantage of a natural experiment created by the firm's health insurance contribution policy. The amount the firm contributes toward retiree health insurance coverage depends on when a person retired and her years of service at that date. As a result of this policy, there is considerable variation in out-of-pocket premiums faced by individuals in the data. This variation is independent of the nonprice attributes of the health insurance plans offered and is plausibly exogenous to individual characteristics that are likely to affect the demand for insurance. A probit model is used to estimate the decision to take-up employer-sponsored health insurance by early retirees between the ages of 55 and 64. Demand for insurance is measured as a function of out-of-pocket premiums and a set of individual characteristics.

Principal Findings

We find that price has a small but statistically significant effect on the decision to take up coverage. Estimated price elasticities range from −0.10 to −0.16, depending on the sample.

Conclusions

The implied elasticities are comparable with results found in previous studies using very different data. Our estimates indicate that policy proposals for a Medicare buy-in or a nongroup tax credit will have a modest impact on take-up rates of near-elderly retirees.