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.
Health insurance; low-income fathers; physical health; men’s health; mental health
The Australian federal government introduced private health insurance incentive policy reforms in 2000 that increased the uptake of private health insurance in Australia. There is currently a lack of evidence on the effect of the policy reforms on access to cardiovascular interventions in public and private hospitals in Australia. The aim was to investigate whether the increased private health insurance uptake influenced trends in emergency and elective coronary artery revascularisation procedures (CARPs) for private and public patients.
We included 34,423 incident CARPs from Western Australia during 1995-2008 in this study. Rates of emergency and elective CARPs were stratified for publicly and privately funded patients. The average annual percent change (AAPC) in trend was calculated before and after 2000 using joinpoint regression.
The rate of emergency CARPs, which were predominantly percutaneous coronary interventions (PCIs) with stenting, increased throughout the study period for both public and private patients (AAPC=12.9%, 95% CI=5.0,22.0 and 14.1%, 95% CI=9.8,18.6, respectively) with no significant difference in trends before and after policy implementation. The rate of elective PCIs with stenting from 2000 onwards remained relatively stable for public patients (AAPC=−6.0, 95% C= −16.9,6.4), but increased by 4.1% on average annually (95% CI=1.8,6.3) for private patients (pdifference=0.04 between groups). This rate increase for private patients was only seen in people aged over 65 years and people residing in high socioeconomic areas.
The private health insurance incentive policy reforms are a likely contributing factor in the shift in 2000 from public to privately-funded elective PCIs with stenting. These reforms as well as the increasing number of private hospitals may have been successful in increasing the availability of publicly-funded beds since 2000.
Health insurance; Coronary artery disease; Revascularisation procedures; Health policy
This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children.
Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) datasets for all ED visits by injured children younger than 19 years of age.
Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36; 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34; 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury: AOR = 0.63; 95% CI = 0.61 to 0.66; moderate and severe injury: AOR = 0.50; 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91; 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11; 95% CI = 2.38 to 4.06).
Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.
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.
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.
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.
An outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
Childhood Cancer Survivors; Health Insurance; Health Care Access; Survivorship; Delivery of Health Care
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.
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.
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.
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.
Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance.
To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare.
Prospective cohort study.
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.
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).
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.
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.
medically uninsured; health status; Medicare
To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.
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.
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.
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.
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.
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.
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.
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.
There is a need for critical evaluation of comprehensive programs in a regional and state context to determine opportunities for improvement.
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.
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.
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.
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.
Currently, the Council of Cooperative Health Insurance (CCHI) is the body responsible for regulating health insurance in the KSA. While the cooperative health insurance schedule (i.e., model policy for health insurance) is available on the CCHI web site, policies related to pharmaceuticals are ambiguous.
The primary objective of this study was to assess the impact of health insurance policies provided by health insurance companies in KSA on access to medication and its use.
Settings and Design
This study was descriptive in design and used a survey, which was conducted through face-to-face interviews with the medical managers of health insurance companies.
Methods and Material
The survey took place between March and June, 2011. All 25 insurance companies accredited by CCHI were eligible to be included in the study. Out of these 25 companies, three were excluded from this survey as no response was received.
All the 16 companies responded “Yes” that they had a prior authorization policy; however, their reasons varied. Eight (50%) of the companies were concerned about the duration of treatment. While 10 (62.5%) did not offer additional coverage over the CCHI model policy, the other 6 (37.5%) reported that they could reconcile certain conditions. The survey also demonstrated that 10 insurance companies allowed refilling of medication but with certain limitations. Six out of the 10 permitted refilling within a maximum time of three months, whereas the other four companies did not have any time-based limits for refilling. The other six companies did not allow refilling without prescription.
Although this paper was primarily descriptive, the findings revealed a substantial scope for improvement in terms of pharmaceutical policy standards and regulation in the health insurance companies in KSA. Additionally, the study highlighted such areas to augment the overall quality use of medication, over-prescribing and irrational use of medication. Further research, thus, is definitely needed.
Delivery of health care; Saudi Arabia; Health insurance; Health care policy
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.
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.
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).
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.
Health insurance; Preterm birth; Neonatal outcomes; Apgar score; Neonatal resuscitation
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.
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.
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.
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.
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.
The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children’s Health, estimating the prevalence of parents’ report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33–63 % and 57–76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public–private difference: 5–34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents’ report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.
Medical home; Public insurance; Disparities; Health policy; National Survey of Children’s Health
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.
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.
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.
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.
Taiwan; Health insurance coverage; Medical expenditure; Coping strategy
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.
1990–2009 CPS Annual Social and Economic Supplement data.
CPS data are enhanced to account for methodological and conceptual changes in health insurance measurement and population control totals.
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.
The enhanced data provide the most consistent measure of health insurance coverage over the past two decades.
Health insurance coverage; Current Population Survey; coverage trends; uninsurance
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.
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.
Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.
U.S. adults age 18 and older (N=6,722).
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.
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.
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.
health care affordability; insurance coverage; low-income populations; functional impairment
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.
Cross sectional analysis of calendar year 2002 insurance enrollees from Western Washington State.
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.
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.
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.
Complementary Therapies; Health Care Costs; Insurance Claim Review; Utilization Review