Coverage & Access
Call for Papers
The Impact of Premiums & Cost Sharing on
Access to Care
Chair: Jessica Banthin, Agency for Healthcare Review and
Quality
Sunday, June 25 • 3:45 pm – 5:15 pm
●The Impact of Cost Sharing on Enrollment, Access, and
Utilization Among Medicaid Beneficiaries: Evidence from
the OHP Cohort Study Wave 2
Matthew Carlson, Ph.D., Bill Wright, Ph.D., Jeanene Smith,
M.D., M.P.H., Tina Edlund, M.S., Heidi Allen, M.S.W.
Presented By: Matthew Carlson, Ph.D., assistant professor,
Sociology, Portland State University, PO Box 751, Portland, OR
97207; Tel: (503) 725-9554; Fax: (503) 725-3957;
Email: carlsonm@pdx.edu
Research Objective: In March, 2003, changes were made to
the Oregon Health Plan (OHP) including increased premiums
and copays, benefit reductions, and a 6-month lockout for
non-payment of premiums. This prospective cohort study
assesses the impact of OHP changes on enrollees’ insurance
status and health care access and utilization over the 18month study period.
Study Design: Data comes from a prospective cohort study of
a subset of OHP beneficiaries who were affected by OHP
changes. A baseline, mail-return survey was conducted in
October, 2003, 6 months after initial OHP changes were
implemented (n=1378, 34% response rate). Twelve months
later, a follow-up survey was conducted by mail and telephone
(n=991, 72% response rate). This analysis examines the
impact of cost sharing by comparing two groups of enrollees
who left the system during the 18-month study period: those
who reported leaving because of increased cost, and those
who reported leaving for other reasons.
Population Studied: Adults age 19 and older who were
enrolled in the OHP for at least thirty days prior to February
15, 2003, just prior to the initial wave of program changes.
Principal Findings: Eighteen months after OHP changes
were implemented, 63% of the OHP standard population
reported losing coverage for 1 or more months, and nearly half
of those who lost coverage (46%) remained uninsured at the
end of the study period. Increased out-of-pocket costs was a
major driver of disenrollment, nearly half who lost coverage
(45%) indicated increased program costs were the main
reason. Moreover, when compared to those who left for other
reasons, those who left because of cost were more likely to
remain uninsured (39% vs. 53%) at the end of the study
period. Cost sharing was also associated with increased
unmet need. Compared to those who left for other reasons,
lost who left because of cost were more likely to report unmet
health care needs (47% vs. 69%) and unmet medication
needs (36% vs. 59%), less likely to have a primary care visit
(73% vs. 64%) and were more than twice as likely to have an
ED visit (14% vs. 36%). Additionally, those who left for other
reasons were only half as likely to report owing more than
$500 in medical debt compared to those who left because of
cost (26% vs. 47%).
Conclusions: Increased program costs resulted in involuntary
loss of coverage for thousands of low-income Oregonians.
Evidence from this study, conducted 18 months after OHP
program changes suggested that cost sharing was a major
barrier to maintaining insurance coverage, and resulted in
high levels of unmet health care needs, increased emergency
room use, and increased the likelihood of medical debt.
Implications for Policy, Delivery, or Practice: Even nominal
cost sharing can impact Medicaid enrollees’ ability to
maintain coverage. Moreover, those who reported losing
coverage as a result of increased program costs fared far
worse than those who left for other reasons. In response to
findings from this and similar studies, in 2006, the OHP will
no longer charge premiums for the lowest income
beneficiaries (0-10% FPL) and will remove the lock-out period
for non-payment of premiums.
Primary Funding Source: CWF, The Robert Wood Johnson
Foundation
●Benefit Design and the Price Elasticity of Demand for
Health Insurance
Sherry Glied, Ph.D.
Presented By: Sherry Glied, Ph.D., Professor and Chair,
Health Policy and Management, Mailman SPH, Columbia
University, 600 West 168th St., 6th Floor, New York, NY
10032; Tel: 212-305-3924; Fax: 212-305-3405;
Email: sag1@columbia.edu
Research Objective: There is considerable support for
expanding health insurance to cover some or all of the
uninsured, but there are substantial differences among
proposals in the nature of coverage that would be provided.
This study examines how the take-up of coverage -- the price
elasticity of demand -- will depend on the nature of the
coverage.
Study Design: I conduct simulation analyses using the
Medical Expenditure Panel Survey, the Survey of Program
Dynamics, and the Rand Health Insurance Experiment, to
estimate reservation prices of alternative coverage packages
for uninsured populations. I estimate the proportion of
uninsured people who would take-up coverage under each of
the options. I use these proportions to compute a demand
curve for health insurance offered at different prices under
each coverage option. I then use this demand curve to
estimate the price elasticity of demand for coverage.
Population Studied: Uninsured adults under 65 with incomes
<200% FPL.
Principal Findings: Different benefit packages will lead to
different rates of participation by the uninsured and will
achieve different public policy goals. Low-income uninsured
people are likely to prefer health insurance that provides frontend protection, rather than coverage that provides protection
in case of a catastrophic illness. For a low-income population,
the estimated price elasticity for a high deductible policy is
about 1/3 as high as for a 100% coverage policy.
Conclusions: Uninsured people have much lower income and
far fewer assets than do those who are already purchasing
coverage. These differences affect the reservation price they
would be willing to pay for different forms of coverage.
Estimates of take-up for policies should take into account the
nature of coverage offered.
Implications for Policy, Delivery, or Practice: Thus,
coverage expansions that seek to solve the problems that
uninsured people face will only be successful if they
incorporate coverage that is at least as comprehensive and
generous as the private market average.
Primary Funding Source: No Funding
●Benefit Design and the Use of Specialty Drugs
Dana Goldman, Ph.D., Geoffrey Joyce, Ph.D., Grant Lawless,
M.D., Ph.D., Vincent Willey, PharmD., William Crown, Ph.D.
Presented By: Dana Goldman, Ph.D., Corporate Chair and
Director, Health Economics, RAND Corporation, 1776 Main
Street, PO Box 2138, Santa Monica, CA 90407-2138; Tel:
(310)451-7017; Fax: (310) 260-8155;
Email: dgoldman@rand.org
Research Objective: Specialty pharmaceuticals (biologic
agents, injectible medications) are high-dollar chronic drug
therapies, often costing more than $1,000 per month..
Coverage of these products varies considerably across plans—
even more so than traditional prescription drugs. This
analysis estimates the financial risk imposed on patients
treated with specialty drugs, and the effects of benefit design
on the use of these products.
Study Design: Our analysis is a retrospective study of
patients enrolled in private health plans. We document the
variability in coverage of specialty pharmaceuticals and the
consequences for plan spending and patients’ out-of-pocket
expenses. We examine how responsive use of specialty
products is to changes in benefit design, and contrast this
demand curve to traditional prescription drugs. We then
simulate how alternative benefit designs affect patient out-ofpocket spending and plan use, including the key policy issue
of whether to cover these products through the pharmacy
benefit.
Population Studied: The data contain up to 4 years of
administrative claims (2001 to 2004) from 50 different health
plans across multiple employers. The data include
information on medical and pharmaceutical claims, and these
data have been linked to detailed benefit designs for each
plan. The study sample consists of privately-insured patients
receiving treatment for cancer, kidney disease, rheumatoid
arthritis and multiple sclerosis (sample sizes range from
2,000-20,000 per condition).
Principal Findings: Patients with these conditions face
substantial financial risk for high out-of-pocket expenses, as
coverage is less generous for these conditions than for the
prototypical beneficiary. The shift towards covering specialty
drugs under the pharmacy benefit rather than the medical
benefit reduces out-of-pocket costs, at least in the short run.
Preliminary results indicate that the demand for specialty
drugs is less price elastic than for oral agents (ranging from –
0.07 to –0.22). This suggests that many specialty drugs are
prime candidates for full insurance coverage.
Conclusions: Specialty drugs are one of the fastest growing
and most expensive categories of prescription drugs. The
high costs of these drugs ? combined with the high medical
costs of treating these conditions ? often result in significant
out-of-pocket expenditures. Covering these products under the
prescription drug plan can reduce total plan costs and patient
out-of-pocket expenditures.
Implications for Policy, Delivery, or Practice: The clinical
and financial effects of specialty pharmaceuticals require new
thinking about the structure of insurance coverage, which is
likely to differ from coverage of traditional oral agents.
Primary Funding Source: NIA, Amgen
●The Impact of Premium Increases on SCHIP Enrollment
in Arizona
Joshua McFeeters, M.P.P., Genevieve Kenney, Ph.D.
Presented By: Joshua McFeeters, M.P.P., Research Associate,
Health Policy, The Urban Institute, 2100 M Street NW,
Washington, DC 20037; Tel: (202) 261-5796; Fax: (202) 2231149; Email: jmcfeete@ui.urban.org
Research Objective: Premiums and other forms of cost
sharing have become a more prominent feature of state public
health insurance programs for children. Between 2002 and
2004, 16 states either implemented new premiums or raised
premiums in their SCHIP programs. Moreover, pending
federal legislation would permit Medicaid programs to
introduce greater cost sharing for children living above the
federal poverty line (FPL). While there is a growing body of
research on the impacts of premiums, there is very little
research on the impacts of premiums for families below 150%
of FPL. This study examines the experience of Arizona’s
SCHIP program, which implemented premiums for children
with incomes less than 150% FPL for the first time in July of
2004 and raised premiums for children with incomes between
150% and 200% of the FPL.
Study Design: This study uses administrative SCHIP
enrollment data from Arizona from 2001 to 2005. The
administrative data include information on age, race, gender,
and family income. Economic conditions are measured using
data on state unemployment and economic growth. A series
of descriptive and multivariate analyses performed include
monthly SCHIP enrollment totals, rate of enrollment growth,
time-series analysis of enrollment trends, and duration
analysis using a Cox proportional hazard model to measure
the rate of disenrollment from SCHIP.
Population Studied: Children in the Arizona Kids Care
Program (Arizona SCHIP).
Principal Findings: Preliminary results indicate that
enrollment in the Arizona SCHIP program for children with
family incomes below 150% of the FPL dropped 15 percent six
months after the implementation of a new premium in July
2004 of $10/month for one child or $15/month for two or
more children. Enrollment declined from 27,692 in June 2004
to 23,506 in December 2004, and enrollment had not returned
to pre-premium levels by September 2005. Duration analysis
of the below 150% of the FPL income group indicates that
after the new premium children were 16 percent more likely to
disenroll from SCHIP than before the implementation of the
premium. The premium increase that was implemented for
the higher income group did not appear to have an adverse
effect enrollment in that income group; in fact, SCHIP
enrollment grew at a higher rate after the premium hike than it
had in the previous period.
Conclusions: The implementation of premium of just $10 or
less per month per child in Arizona’s SCHIP program for
children with family incomes below 150% FPL was associated
with a significant enrollment decline for that income group.
Implications for Policy, Delivery, or Practice: This analysis
suggests that for near poor families, even modest premiums
can lead to reductions in caseloads. While this analysis does
not provide direct evidence on the coverage implications of
the premium increase, other data suggest that many publicly
covered children in this income group do not have access to
employer-sponsored coverage. Thus, many of the children
losing public coverage due to the premium increase may
become uninsured and experience access problems. The
results suggest that there may be some scope for raising
premium levels for higher-income children covered by SCHIP.
Primary Funding Source: Children's Action Alliance
●Annual Re-Enrollment in the State Children's Health
Insurance Program (SCHIP): Factors That Influence
Parents’ Decisions to Continue, Change, or Terminate
SCHIP Coverage
Laura Shone, Dr.P.H., M.S.W., Jonathan D. Klein, M.D.,
M.P.H., Alina Bajorska, MS, Peter G. Szilagyi, M.D., M.P.H.
7%, p<.05); “SCHIP and private insurance are different” (75%,
56%, 43%, p<.01). The mean reported “Amount per month
SCHIP is worth” was $60 among those who became
uninsured, $104 among SCHIP re-enrollers, and $113 among
those who obtained other coverage – either Medicaid or
private insurance (p<.01).
Conclusions: Most children re-enroll in SCHIP, however, the
re-enrollment process contributes to coverage lapses and
SCHIP exit. Becoming uninsured after SCHIP is associated
with having reported no medical visits during SCHIP and
negative experiences with or perceptions of SCHIP during the
child’s SCHIP enrollment.
Implications for Policy, Delivery, or Practice: Future
strategies should focus on uninterrupted retention of children
already enrolled in SCHIP, whether through passive
recertification or assistance with re-enrollment, as well as
efforts to identify and address concerns of enrollees who do
not use care or are dissatisfied with SCHIP.
Primary Funding Source: AHRQ
Call for Papers
Presented By: Laura Shone, Dr.P.H., M.S.W., Assistant
Professor, Pediatrics, University of Rochester, School of
Medicine, 601 Elmwood Ave, Box 777, Rochester, NY, 14642;
Tel: 585-273-4084; Email: Laura_Shone@urmc.rochester.edu
Research Objective: Rationale: Enrollment retention is a
significant challenge in SCHIP. Attrition peaks at times when
active re-enrollment/renewal is required, and children may
become uninsured rather than re-enroll in SCHIP. Little is
known about the factors that influence parents’ decisions to
continue, change or terminate SCHIP coverage.
Objective: Among SCHIP enrollees throughout one large
state, 1) Describe the proportions of children who re-enroll in
SCHIP for a second year compared to those who obtain other
coverage and those who become uninsured; 2) Identify factors
associated with changing coverage or becoming uninsured
after holding SCHIP coverage.
Study Design: Pre-post parent telephone interview shortly
after enrollment and 1 year later, for measures of insurance
coverage; access, use, and satisfaction with medical care;
perceptions of SCHIP and other insurance; and experiences
with annual SCHIP recertification process. Bivariate and
multivariate analyses were performed using STATA 8.0 to
provide weighted statewide estimates.
Population Studied: Random sample of new enrollees in
New York State’s SCHIP, stratified by age, race, and NYS
region (Time One n=2,644; Time Two n=2,290; 87%).
Principal Findings: Seven percent of children lost SCHIP
eligibility (e.g. “aged out” or “family income too high”). Of the
remainder, 86.3% re-enrolled in SCHIP and 13.6% exited -either to other coverage (8.2% overall; 4.6% private and 3.6%
Medicaid) or became uninsured (5.4%). Problems with the reenrollment process led to coverage lapses for 6.2% of reenrollers and to SCHIP termination for 17% of exiters.
Children who became uninsured after SCHIP, compared with
those who re-enrolled in SCHIP or obtained other coverage,
were significantly more likely to report: Having no visits during
SCHIP (18 %, 10%, 2 % respectively, p<.001); “Less satisfied
with SCHIP physician vs. pre-SCHIP physician (18%, 5%, 7%,
p<.001); “Physician does not respect me” (24%, 6%, 4%,
p<.001); “My child not treated well due to SCHIP” (23%, 9%,
Uninsurance: Measurement, Costs & Outcomes
Chair: Lynn Blewett, University of Minnesota
Sunday, June 25 • 5:45 pm – 7:15 pm
●Why are Survey Counts of Medicaid Enrollees Lower than
Administrative Enrollment Counts? A Match Study
Between the Current Population Survey and the Medicaid
Statistical Information System
Michael Davern, Ph.D., Dean Resnick, David Baugh, Robert
Stweart, George Greenberg, Kathleen Thiede Call, Ph.D.
Presented By: Michael Davern, Ph.D., Assistant Professor,
SHADAC, University of Minnesota, 2221 University Ave. SE
Suite 345, Minneapolis, MN 55414; Tel: 612-625-4835; Fax: 612624-1493; Email: daver004@umn.edu
Research Objective: Survey counts of those enrolled in
Medicaid are significantly lower than administrative data
counts. Because surveys are the only source of information
on key policy populations like the uninsured, and those who
are eligible for Medicaid but not enrolled, this disparity can
have significant implications depending on why the two
counts are systematically different. We examine four main
types of explanations and their implications for policy
research. The first explanation could be that Medicaid
enrollees answer surveys as though they are uninsured (and
as a result the count of uninsured people from surveys is
incorrect). Second, Medicaid enrollees are systematically left
off survey sampling frames or are more likely to not respond
to surveys than those not enrolled in Medicaid. Third,
Medicaid enrollees answer surveys by naming some other
type of health insurance coverage (e.g., “Medicare”). Fourth,
administrative data could “over-count” the Medicaid
population.
Study Design: In an attempt to determine the extent to which
any (or all) of these possible explanations are in operation we
match the Center’s for Medicare and Medicaid Services (CMS)
Medicaid Statistical Information System (MSIS) and Medicare
Enrollment Database (MEDB) to two surveys with health
insurance coverage information (the Current Population
Survey’s Annual Social and Economic supplement -CPSASEC- and the National Health Interview Survey) as well as
the Census Bureau’s Master Address File (MAF). We put the
CMS enrollment data through the PRED validation system at
the Census Bureau to validate social security numbers (SSNs)
and then we use SSNs, age and sex to match the data to the
survey data and MAF. Ninety two percent of the MSIS data
have a valid SSN and 94% of the CPS-ASEC data have a valid
SSN. The CPS-ASEC cases for 2001 and 2002 will be matched
to the MSIS from 2000-2003. We expect approximately
30,000 matched cases.
Population Studied: Medicaid enrollees on the MSIS
enrollment data file and the non-institutionalized US
population in 2001 and 2002.
Principal Findings: By March 2006 we know the extent to
which the uninsurance estimates from the CPS-ASEC are
biased due to people who have Medicaid coverage reporting
that they are uninsured. We will also determine the rates at
which people who have Medicaid coverage report some other
type of health insurance coverage (either in combination with
Medicaid or not) in the CPS-ASEC. And finally, we will
determine the rate at which people who probably do not have
Medicaid coverage report having Medicaid coverage in the
CPS-ASEC.
Conclusions: Using the data analysis we will make
recommendations concerning survey instrument
improvement for measuring the Medicaid population, the
uninsured, and those with more than one type of coverage
(e.g., Medicaid and Medicare). We will also have
recommendations for policy analysts using the CPS-ASEC data
to estimate essential policy subpopulations like the eligible but
uninsured population.
Implications for Policy, Delivery, or Practice: Our
conclusions will help policy simulations that estimate
important groups like the eligible but uninsured group in their
policy simulations that are used to evaluate proposed and
implemented health policy.
Primary Funding Source: RWJF, Health and Human Services
●Expanding Medicaid May Cost Less Than You Think:
Evidence from Health Insurance Churning in the 19982002 MEPS
Danielle Ferry, ABD, Sherry Glied, MA, Ph.D., Kathryn Klein,
M.P.H.
Presented By: Danielle Ferry, ABD, National Bureau of
Economic Research, 92 Atlantic Ave., Apt. 4D, Brooklyn, NY
11201; Tel: 917/822-6674; Email: dferry@nber.org
Research Objective: Thirty percent of low-income individuals
covered by Medicaid in January of 1998 or 1999 experienced at
least one spell of uninsurance in the subsequent two years.
Many may find extensive and regular recertification
requirements too complicated and taxing to bother with. For
similar reasons, others may never enroll in the first place. The
gap between eligibility and enrollment and the link between
lack of health coverage and unmet health needs has spurred
interest in expanding Medicaid enrollment by reducing
administrative barriers. A more ambitious proposal would
extend Medicaid eligibility to anyone without health coverage.
This study explores the costs of expanding Medicaid to the
uninsured and of using simpler recertification procedures to
increase enrollment among those currently eligible.
Study Design: We use month-to-month health insurance
transitions, expenditures, and service utilization patterns, to
compare the health needs of, first: 1) those who were
consistently uninsured, 2) those who were consistently
enrolled in Medicaid, and 3) those who transitioned from no
coverage to Medicaid; and second: 1) those who were
consistently enrolled in Medicaid and 2) those who
transitioned off of Medicaid. If the decision to enroll in or
maintain Medicaid is correlated with health needs, then we
expect the pre-transition expenditures of those who gained
Medicaid coverage to exceed those of individuals who were
persistently uninsured and the pre-transition spending of
those who left Medicaid to fall below that of individuals who
were enrolled in Medicaid constantly.
Population Studied: We use data on 45,650 adults who
participated in the Medical Expenditure Panel Survey (MEPS)
for two full years between 1998 and 2002 and for whom health
insurance information is available for all 24 months.
Participants wer ages 19-62 in their first year on the panel.
Principal Findings: Our findings support these hypotheses.
In the month prior to enrollment, the average expenditures of
the consistently uninsured are less than one-quarter of those
of “new” Medicaid enrollees and just 17 percent as high as
those of long-term Medicaid enrollees. The monthly spending
of those who gave up Medicaid to become uninsured, in the
month prior to switching, is 65 percent of that of individuals
who maintained their enrollment.
Conclusions: These results suggests that the costs associated
with expanding Medicaid coverage are likely to be less than
what can be extrapolated directly from an examination of
either the current Medicaid population or those individuals
who currently choose to enroll. Our conclusions are robust to
a number of sensitivity analyses, including disaggregating
expenditures by type, including the cost of uncompensated
care in expenditure figures, restricting the sample to
individuals with chronic conditions, substituting health care
utilization for expenditures, and extending the comparison
period from one month to two or four months.
Implications for Policy, Delivery, or Practice: States should
consider both expanding Medicaid eligibility and working to
improve retention among those beneficiaries who are
currently eligible as a viable approach to the problem of the
uninsured.
Primary Funding Source: CWF
●Do Gaps in Health Insurance Make a Difference?
Jane Griffin, M.P.H., Tricia Leddy, MS, Christine Payne, Ph.D.,
Melinda Thomas, MS
Presented By: Jane Griffin, M.P.H., Project Director, Rhode
Island Department of Human Services, Medicaid Research
and Evaluation Project, RIte Care Program, 600 New London
Avenue, Cranston, RI 02920; Tel: 401-462-6330; Fax: 401-4626353; Email: jgriffin@dhs.ri.gov
Research Objective: To determine the effect of disruption of
health coverage on access utilization and unmet health needs
for a cohort of children continuously for at least one year in
Medicaid managed care program.
Study Design: This is a follow-up cohort study. Rhode
Island’s Medicaid Management Information System (MMIS)
was used to create a retrospective cohort of children <=18 who
were continuously enrolled in RIte Care for one year. This
group was stratified into gap groups according to number of
months uninsured in the subsequent year. A follow-up CATI
phone survey was conducted with parents that measured
health coverage, utilization, barriers to care, health status, and
unmet need.
Population Studied: Phone interviews were conducted with
660 parents. In the follow-up year two hundred and ninety
(290) of the children had intermittent health coverage
(uninsured average of 5.4 months in year) and 370 children
had continuous coverage.
Principal Findings: Hispanic children, especially if their
parents do not speak English, were significantly more likely to
have intermittent coverage. Children with intermittent
coverage were significantly more likely to live in families that
experienced other household disruptions including moving
(25.5%), parents changed jobs (34.1%), family without phone
(18.6%), parents without health insurance (58.6%) and
parents unable to pay mortgage (25.5%). Both children with
gaps and children with continuous coverage had a usual
source of care (96.7% and 99.2% respectively). However,
children with intermittent coverage faced greater difficulty
getting medical care (28.3% compared to 7.4%). Children
with disruptions in coverage were significantly more likely to
have unmet needs for dental care (37.6%), prescription
medication (20.8%), specialty care (29.1%), and mental health
care (28.0%. Despite problems with access to care, children
with intermittent health insurance received the same number
of preventive,acute and specialty visits as children with
continuous coverage. In addition children with gaps in
coverage had the same health status at one year as children
with continuous coverage as measured by ability to participate
in usual activity and number of chronic conditions.
Conclusions: Children on Medicaid managed care with
intermittent health insurance coverage for one year following
twelve months of continuous public coverage face more
barriers and reported more unmet need than children with
continuous health coverage. Their families experience more
life disruptions including parents changing jobs, moving, and
other economic hardships. Children with gaps in coverage
were more likely to be minority and speak Spanish. Although
having gaps in insurance created difficulty in obtaining care,
children with gaps in coverage had the same number of visits
as children with continuous coverage and there was no
evidence of erosion in health status
Implications for Policy, Delivery, or Practice: Disruptions in
health care coverage creates hardships in the lives of lowincome families. Children who have gaps in coverage face
barriers to obtaining needed care. However, children who have
a medical home for at least one year continue to have a usual
place of care and similar utlization even if they experience
gaps in health coverage.
Primary Funding Source: RWJF
●The Effects of Being Uninsured on Mortality and
Morbidity
Richard Kronick, Ph.D.
Presented By: Richard Kronick, Ph.D., AcademyHealth/NCHS
Fellow, Division of Health Care Statistics, National Center for
Health Statistics, 3311 Toledo Road, Hyattsville, MD 20782;
Tel: 301-458-4577; Email: rkronick@cdc.gov
Research Objective: The purpose of this research is to
improve our estimates of the effects of being uninsured on
mortality and morbidity. In a much cited 2002 report Care
Without Coverage, Too Little, Too Late, the Institute of
Medicine estimated that lack of insurance led to 18,000 excess
deaths annually among 25-64 year olds. In a subsequent IoM
report, Elizabeth Vigdor estimated that lack of insurance in the
United States leads to an annual loss of between $65-$130
billion in ‘health capital’. However, as both the 2002 IoM
report and Vigdor acknowledged, estimates of the magnitude
of the effect of lack of insurance on morbidity and mortality
are quite uncertain. The estimate of 18,000 excess deaths is
largely based on two population-based sample surveys
comparing subsequent mortality of respondents who were
insured at baseline with those who were uninsured. One
study was based on approximately 4,700 respondents who
were interviewed in the early 1970s. The other uses a larger
sample of 150,000 respondents from the Current Population
Survey interviewed in the mid-1980s, but is limited to
rudimentary controls for baseline health status. And Vigdor’s
estimate of the effects of lack of insurance on morbidity
estimates an effect of somewhere between $0 and $65 billion
loss in health capital annually -- a rather wide range.
Study Design: We use data from the National Health
Interview Surveys from 1986 through 2000, which have been
linked with the 2002 National Death Index. The NHIS is a
national multistage probability sample of the civilian
noninstitutionalized population. For approximately 500,000
adults in the combined 1986-2000 NHIS samples, we
estimated Cox proportional hazard regressions to estimate the
probability of death, controlling for a wide range of baseline
characteristics. We provide both straightforward estimates of
the effects of being uninsured at baseline, as well as
Instrumental Variable estimates. In the IV estimates the key
instrument is the generosity of the state Medicaid program
during the survey year. We take advantage of changes over
time in relative generosity (e.g., Tennessee Medicaid
generosity increased substantially between 1986 and 2000) to
measure whether these largely exogenous changes in
Medicaid generosity are related to patterns of morbidity and
mortality. We also analyze whether the mortality differential
between the insured and uninsured narrows after age 65, on
the thought that if poor access to care is the major factor
contributing to poor outcomes, then nearly universal Medicare
coverage at age 65 should narrow the mortality differential.
Population Studied: Approximately 500,000 respondents
from the 1986-2000 NHIS, with up to sixteen years of followup mortality data from the NDI.
Principal Findings: Similar to the results from earlier work,
preliminary results from the Cox proportional hazard
regressions estimate that mortality rates for the uninsured are
approximately 15% to 25% higher than for the privately
insured. However, at age 65 the mortality differential does not
appear to narrow significantly. The Instrumental Variables
estimates and estimates of the effects of lack of insurance on
morbidity have not yet been completed.
Conclusions: Not yet known.
Implications for Policy, Delivery, or Practice: It is expected
that policy makers will benefit from more precise estimates of
the effects of lack of insurance on morbidity and mortality. It
is also hoped that greater precision in the estimates of the
effects of insurance on health will provide the information that
estimating agencies (such as CBO, OMB, their counterparts
in state legislatures, and private firms such as Lewin) need to
be comfortably in expanding the scope of their estimates of
health care reform proposals, to include not simply estimates
of the number of people covered, and the public and private
sector costs, but also of the health benefits of expanded
coverage.
Primary Funding Source: National Center for Health
Statistics
●How Did SCHIP Affect the Insurance Coverage of
Immigrant Children?
Anthony Lo Sasso, Ph.D., Thomas Buchmueller, Ph.D.,
Kathleen Wong
Presented By: Anthony Lo Sasso, Ph.D., Associate Professor,
Health Policy and Administration, University of Illinois at
Chicago, 1603 W. Taylor, Chicago, IL 60612; Tel: (312) 4131312; Fax: (312) 996-5356; Email: losasso@uic.edu
Research Objective: In the past two decades there have been
substantial initiatives at the state and federal levels aimed at
increasing insurance coverage among children. However, it is
estimated that over 6 million children who are eligible for
public insurance remain uninsured. A crucial first step for
addressing this problem is to determine how the take-up of
public coverage varies within the population. Children of
immigrants are an especially important group to consider as
foreign-born adults are nearly three times as likely to be
uninsured as native-born Americans and their children are
also more likely to be uninsured than children whose parents
were born in the US. We test whether the effect of the SCHIP
expansion was different for children of foreign-born and USborn parents.
Study Design: The analysis is based on repeat cross-section
data from the Current Population Survey. We use an
instrumental variables approach in which the effect of SCHIP
eligibility is identified by cross-state differences in the timing
and extent of changes in the income eligibility limit over the
period from 1996 to 2003. We test for the effect of SCHIP on
insurance coverage from any source as well as on the
probability of having public insurance (take-up) and on the
probability of having private coverage (crowd-out), and how
this effect differs between the children of native and foreignborn parents.
Population Studied: A nationally representative sample of
children aged 0-18.
Principal Findings: Our results suggest that take-up among
the children of the foreign born was at least as high as natives
and in some specifications considerably higher. In our
preferred specification, take-up rates for public insurance were
roughly twice as large for children of foreign-born parents than
for children of natives: approximately 20% versus 9%,
respectively. In addition, private health insurance crowd-out
was significantly lower among children of immigrants: crowd-
out for children of natives was nearly 50% while for children of
immigrants it was roughly 25%.
Conclusions: Our crowd-out finding contrasts strikingly with
recent research on the impact of welfare reform found that
reductions in public coverage among immigrants were
completely offset by increases in private coverage, implying
100% substitution. However, because immigrants are so
much less likely to have private insurance than natives it is
perhaps not surprising that crowd-out is less of an issue.
Similarly, our results showing stronger take-up among the
children of immigrants are at odds with prior research. Yet,
given the high rates of uninsurance among immigrants
relative to natives, it is again perhaps not surprising that
public expansions would find greater success among
immigrants.
Implications for Policy, Delivery, or Practice: Because
SCHIP was enacted just after the 1996 Federal welfare reform
legislation, which singled out recent immigrants for harsh
treatment, there is reason to expect that SCHIP’s effect on
coverage might have been smaller for children of immigrants.
However, if outreach efforts to market SCHIP in languages
other than English were effective, nativity-related differences in
take-up may be less in the case of SCHIP as compared to
earlier expansions. Our results have important implications
for policy makers looking to further refine efforts to encourage
enrollment in public insurance programs by vulnerable
populations.
Primary Funding Source: RWJF
Call for Papers
Older & Sicker: Access & Coverage Issues
Chair: Deborah Chollet, Mathematica Policy Research, Inc.
Monday, June 26 • 8:30 am – 10:00 am
●A Theory of Health Disparities and Medical Technology
Geoffrey Joyce, Ph.D., Dana Goldman, Ph.D., Pinar KaracaMandic, Ph.D.
Presented By: Geoffrey Joyce, Ph.D., Senior Economist,
RAND Corporation, 1776 Main Street, PO Box 2138, Santa
Monica, CA 90407-2138; Tel: (310)393-0411 ext 6779; Fax: (310)
260-8155; Email: Geoffrey_Joyce@rand.org
Research Objective: The standard Medicare drug benefit
(Part D) contains sizeable gaps in coverage for people who
spend moderate to high amounts on prescription drugs. This
gap or “doughnut-hole” creates a non-linear price schedule
with price uncertainty since consumers cannot precisely
forecast how much they will spend during the year. Changes
in pharmaceutical use—especially discontinuation of
efficacious therapy—could have important health
consequences for elderly beneficiaries with diabetes, asthma
and other chronic conditions.
Study Design: We examine outpatient medication use among
retirees age 65 and older who have employer-provided drug
coverage with a spending cap of $2,500 per year. We
examine whether the elderly behave in a myopic or rational
manner—that is, do they change their behavior as they
approach the cap but do not exceed it. We examine
continuation of pharmacy use after patients exceed the cap
and their use of prescription medications when coverage
resumes in January. We also estimate the use of generic
medications and mail-order services before and after
exceeding the cap. To assess the potential health
consequences, we examine use of medical services in the
subsequent year (overall and by type of service) among
patients who did and did not exceed the cap.
Population Studied: The data include two years (2003-2004)
of medical and pharmacy claims on more than 40,000
retirees age 65 and older are enrolled in a private health plan
with an annual spending cap of $2,500 for outpatient
prescription drugs. We obtained pharmacy transaction data
for a subsample of beneficiaries to capture their use (cash
purchases) of prescription drugs after exceeding the cap.
Principal Findings: Preliminary analyses suggest that the
majority of beneficiaries who exceed the annual spending cap
continue to purchase medications for a chronic illness. They
are more like purchase generic medications and have larger
gaps between refills than before reaching the cap and
compared to those who did not exceed the cap. Future work
will examine whether this pattern is consistent across
therapeutic classes and how spending caps affect pharmacy
and medical care utilization in the subsequent year.
Conclusions: Preliminary findings suggest that beneficiaries
with moderate to high drug expenses, particularly the
chronically ill, face longer gaps in coverage and are more
susceptible to interruptions in insurance. Discontinuation of
efficacious therapy could have important health consequences
for elderly beneficiaries with diabetes, asthma and other
chronic conditions.
Implications for Policy, Delivery, or Practice: Cycling into
and out of coverage may be more disruptive to care plans
than a stable benefit with higher coinsurance.
Primary Funding Source: NIA
●Impact of State Mandatory Insurance Coverage on
Selected Diabetes Care Services
Rui Li, Ph.D, Ping Zhang, Ph.D., DeKeely Hartsfield, M.P.H.
Presented By: Rui Li, Ph.D, Prevention Effectiveness Fellow,
Division of Diabetes Translation, Centers for Disease Control
and Prevention, 4770 Buford Hwy, N.E. MS K-10, Atlanta, GA
30341; Tel: (770)488-1070; Fax: (770)488-1148;
Email: Rli2@cdc.gov
Research Objective: Diabetes is a costly disease in the United
States with serious complications such as blindness,
amputation and end-stage renal diseases. The development of
diabetes complications, however, can be prevented or delayed
by good diabetes care. To improve access to care and quality
of care for diabetes patients, many states have passed laws
that mandate private insurance to cover certain diabetes care
services, devices and supplies. This research is to examine the
coverage of these laws and their impact on the diabetes care
services.
Study Design: We assembled all legal documents related to
private insurance coverage of diabetes care in all 50 states,
and categorized the coverage. We used a hierarchical logistic
regression model to examine the independent association
between the state laws and the services, including daily selfmonitoring blood sugar level, annual eye exams, annual foot
exams, as well as the use of all three services. Disease
conditions, persons’ demographic characteristics and time
effects were adjusted.
Population Studied: Data for the regression analysis was
from the 1996 to 2000 Behavioral Risk Factor Surveillance
System (BRFSS), an annual, state-based, random telephonesurvey of 150,000-210,000 community-dwelling US adults.
Only people with diabetes and covered by employer-provided
insurance or self-bought insurance (n=9215) were included in
these analyses.
Principal Findings: Forty-six states had laws governing
diabetes care but the extent of this coverage varied
considerably. Forty states covered self-management
education; 12 states covered therapeutic footwear; and only 3
states specified the coverage for eye and foot exams. In
addition, 5 states covered HbA1c test and 41 states had
general coverage of pharmaceuticals, devices, and supplies.
Before the state mandatory law, 42% of persons with diabetes
performed daily SMBG. Sixty-three percent received annual
dilated eye exams, and 57% received annual foot exams. Only
23% of person with diabetes received all three of the services.
The impact of legislation varied depending on the
components of the laws and the type of services. Mandatory
coverage of devices and supplies increased a person’s
likelihood of daily SMBG by 2 percentage points (Not
significant) in the first year after the laws were passed, and 4
percentage points (p<=0.05) in the following years. Other
coverage had no significant effect on any of the relevant
services. However, state laws increased the probability of all
three services by 7 percentage points (p<=0.001) in the first
year, and 5 percentage points (p<=0.01) in the subsequent
years.
Conclusions: Coverage of state laws on diabetes services,
devices and supplies were heterogeneous. Overall, the state
mandatory insurance coverage had some effect on the
utilization of diabetes care services.
Implications for Policy, Delivery, or Practice: Laws and
regulations can be an effective policy tool to improve the
quality of diabetes care. Reasons why the coverage of state
laws has different effects on different services need to be
further investigated.
Primary Funding Source: No Funding
●Medicare to the Rescue: Intensity of Health Services and
Costs of Care for Previously Uninsured Adults with
Chronic Conditions
J. Michael McWilliams, M.D., Alan M. Zaslavsky, Ph.D., Ellen
Meara, Ph.D., John Z. Ayanian, M.D., M.P.P.
Presented By: J. Michael McWilliams, M.D., General
Medicine Fellow, Department of Health Care Policy, and
Division of General Medicine, Harvard Medical School and
Brigham and Women's Hospital, 75 Francis Street, Boston,
MA 02115; Tel: 617-732-6043;
Email: mmcwilliams@partners.org
Research Objective: To compare the differential impact of
gaining Medicare coverage on rates of hospitalization, use of
physician visits, and total medical expenditures for previously
insured and uninsured adults with chronic disease.
Study Design: Using a natural experiment design and
longitudinal data from years 1992-2004 of the nationally
representative Health and Retirement Study, we examined
differences in self-reported hospitalizations, physician visits,
and medical expenditures at multiple biannual intervals before
and after adults became eligible for Medicare at age 65. We
modeled the number of hospitalizations and physician visits
and total medical expenditures in each two-year period as a
function of prior insurance status, allowing for differences
before and after age 65 and adjusting for gender, race,
income, education, and self-reported health at baseline. All
analyses included sampling weights and multilevel random
effects to account for survey design and longitudinally
correlated data.
Population Studied: A total of 2263 adults aged 54-61 in 1992
and 66-73 in 2004 who reported being diagnosed with
hypertension, diabetes, or heart disease by age 64, and who
were classified as continuously insured (n=2008) or
continuously uninsured (n=255) from ages 60-64. Because
expenditure data were available only through 2002, we
expanded the uninsured group to include those who were ever
uninsured prior to age 65 (total n=625) to increase power to
detect differences in spending. Adults with public insurance
before age 65 were excluded.
Principal Findings: Adjusted increases in rates of
hospitalizations, physician visits, and total medical
expenditures were significantly greater for previously
uninsured than previously insured adults (greater by 0.26
hospitalizations/2 years(2y), P=0.005; 5.6 physician visits/2y,
P<0.001; and $6199/2y, P=0.01)). Despite worse self-reported
health status, adjusted hospitalization rates tended to be
lower for previously uninsured than insured adults prior to age
65 (0.09 hospitalizations/2y lower, P=0.13) but were
significantly higher after age 65 (0.25 hospitalizations/2y
higher, P=0.046). Similarly, adjusted physician visit rates
were significantly lower for previously uninsured adults before
age 65 (2.3 visits/2y lower, P=0.02) but significantly higher
after age 65 (5.6 visits/2y higher, P=0.02). Adjusted medical
expenditures were also significantly lower for previously
uninsured adults before age 65 ($2579/2y lower, P=0.009) but
significantly higher after age 65 ($5826/2y higher, P=0.045).
Conclusions: After gaining Medicare coverage, increases in
hospitalizations, physician visits, and expenditures were
substantially greater for previously uninsured than previously
insured adults. Moreover, after adjusting for several
confounding characteristics, the excess utilization for
previously uninsured adults after age 65 greatly exceeded their
under-utilization prior to age 65.
Implications for Policy, Delivery, or Practice: Uninsured
near-elderly adults with chronic conditions may experience
greater morbidity, use health services more intensively, and
require more costly care as Medicare beneficiaries than they
would if insured prior to age 65. Furthermore, their increased
use of medical services and related expenditures after age 65
may be substantially greater than their lower costs of care
before age 65. Therefore, expanding insurance coverage and
access to appropriate care for uninsured near-elderly adults
with chronic conditions may offset Medicare expenditures
considerably after age 65 by addressing the health needs of
this vulnerable population at an earlier age.
Primary Funding Source: AHRQ
●Veterans Using and Uninsured Veterans not Using VA
Health Care
Karin Nelson, M.D., M.S.H.S., Gordon A. Starkebaum, M.D.,
Gayle E. Reiber, Ph.D., M.P.H.
Presented By: Karin Nelson, M.D., M.S.H.S., Staff Physician,
Assistant Professor, Department of Medicine, University of
Washington, VA Puget Sound, 1660 South Columbian Way, S111-GIMC, Seattle, WA 98108; Tel: 206-277-5118; Fax: 206-7642849; Email: Karin.nelson@va.gov
Research Objective: (1) To examine veteran reliance on
health services provided by the VA, (2) to describe the
characteristics of veterans who receive VA care and (3) to
report rates of uninsurance among veterans and
characteristics of uninsured veterans.
Study Design: We analyzed data from the 2000 Behavioral
Risk Factor Surveillance System, a cross-sectional national
telephone survey. Using bivariate and multivariate analyses,
we examined the association of veteran's demographic
characteristics, health insurance coverage and use of VA
services. Veterans not reporting VA coverage and having no
other source of health insurance were considered uninsured.
Population Studied: Nationally representative sample of US
veterans (n=23,797).
Principal Findings: Among US veterans, 6.2% report
receiving all of their health care at the VA, 6.9% report
receiving some of their health care at the VA and 86.9% did
not use VA health care. Poor, less-educated and minority
veterans are more likely to receive all of their health care at the
VA. Veterans under 65 who utilize the VA for all of their health
care also report coverage with either private insurance
(42.6%) or Medicare (36.3%). Of the under-65 veterans, 8.6%
(an estimated 1.3 million individuals) were uninsured.
Uninsured veterans were less likely to be able to afford a
doctor or see a doctor within the last year.
Conclusions: Veterans who utilize the VA for all of their
health care are more likely to be from disadvantaged groups.
A large number of veterans who could use VA services were
uninsured.
Implications for Policy, Delivery, or Practice: We found that
the majority of veterans who are eligible for VA health care
services do not use the VA. As the US looks for strategies to
reduce the existing number of uninsured, expanding existing
federal programs is one possible solution. Although our study
suggests that the Department of Veterans Affairs provides
services to individuals from disadvantaged groups including
veterans from poor, less educated and minority populations, a
significant number of veterans remained uninsured. The large
number of uninsured veterans who report not using VA
services should be a target population for VA recruitment and
enrollment efforts, especially given increasing evidence on the
detrimental clinical effects of not having health insurance.
Health care and preventive practices are indicated to minimize
future morbidity among our uninsured veterans.
Primary Funding Source: VA
●The Decline in Employer-Sponsored Health Insurance
Coverage for Retirees and Its Impact on Older Americans
Erin Strumpf, B.A.
Presented By: Erin Strumpf, B.A., Health Policy, Harvard
University, NBER, 1050 Massachusetts Ave., 3rd Fl.,
Cambridge, MA 02138; Tel: (617) 588-1483; Fax: (617) 8685023; Email: strumpf@fas.harvard.edu
Research Objective: Over the last decade, in the face of
rapidly increasing health care costs, the aging of the American
population, and accounting policy changes, many employers
have discontinued health insurance coverage offerings to
retirees. While coverage rates for current retirees have
remained relatively constant, offer rates among large
employers have declined by about 50 percent since 1988. This
decline portends a large drop in coverage rates for future
retirees and the consequences of this sea change remain
unexamined. This paper explores the likely implications of
this coverage decline by investigating the effect of employersponsored retiree health insurance (RHI) offer on the
retirement decision, health insurance coverage, and the health
care spending, utilization and health status of older
Americans.
Study Design: I follow a panel of older individuals who all
have employer-sponsored health insurance coverage in 1992.
I examine differences in the subsequent retirement, health
insurance coverage, health care utilization, health spending,
and health status of those who were and were not offered RHI
by their employer. The under age 65 and age 65+ populations
are analyzed separately and controls are included for
demographics, health and family characteristics.
Population Studied: Health and Retirement Survey (HRS)
respondents who are aged 47-63 and have employersponsored health insurance in 1992 are followed over ten
years (1992-2002).
Principal Findings: Preliminary findings suggest that
individuals under age 65 who are offered RHI are more likely
to retire and more likely to have health insurance coverage in
retirement. There is also some evidence of a positive
association between RHI offerings and various measures of
health care utilization. In the top half of the spending
distribution, out-of-pocket medical spending is significantly
lower for those with RHI offer than for those without. While
the results on health status show much smaller and
statistically insignificant effects, the results from a two-stage
model using propensity score matching will account for
endogeneity which may bias these results toward zero.
Conclusions: These results indicate that we can expect
declines in RHI offer rates to have sizeable impacts on the
retirement behavior of older workers which may have spillover
effects on the labor market opportunities available to younger
workers. Declines in RHI offer rates may result in increased
financial risk and changes in health care utilization patterns
for the near-elderly. Future work will explore the impact on
health more carefully.
Implications for Policy, Delivery, or Practice: The decline in
rates of RHI offer by employers may leave many future retirees
with fewer options for affordable coverage. Given the effects
of this large change in health insurance options for older
Americans, policymakers might consider options to
strengthen the system of employer-sponsored coverage
and/or ways to make other adequate and affordable insurance
options available through public or private means.
Furthermore, RHI is an important source of prescription drug
coverage and the consequences of changes in these benefits
will merit close attention as the Medicare prescription drug
benefit is implemented.
Primary Funding Source: NIA
Related Posters
Coverage & Access
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●Patient Assistance Programs in Massachusetts
Community Health Centers
Alexy Arauz Boudreau, M.D., M.P.H.
Presented By: Alexy Arauz Boudreau, M.D., M.P.H., Fellow,
MGH Center for Child and Adolescent Health Policy,
Massachusetts General Hospital for Children, 50 Stanifor
Street, Suite 901, Boston, MA 02114; Tel: 617 726-2337; Fax:
617 726-1886; Email: aarauz@partners.org
Research Objective: Patient Assistance Programs (PAP) are
charitable programs offered by pharmaceutical manufactures.
There are 150-200 different PAP, each with its own application
procedures making them difficult to operate. Community
Health Centers (CHC) are encouraged to use 340 B
pharmaceuticals, a federal regulation allowing qualified
entities to purchase pharmaceuticals at prices exempt from
Medicaid “best price” arrangements saving states health care
dollars. Our goal is to assess 1) how and if Massachusetts’
CHC are utilizing PAP, 2) CHC costs to run the programs, and
3) how they may be integrated with 340 B pharmaceuticals.
Study Design: We performed guided interviews with
Executive Directors of MACHC. Executive directors included
pharmacy directors and other personnel at their discretion.
Common themes regarding the benefits and drawback of PAP
were identified with conceptual analysis. We used costing
analysis to obtain the cost per PAP successfully processed and
the benefit to cost ratio per site.
Population Studied: We identified a representative sample of
CHC (14/50) based on their location in the State, number of
patients, and availability of pharmacy services.
Principal Findings: Eleven centers accepted interviews with 6
submitting costing data. Nine centers operated PAP in a
systematic manner. Three organizational models were
identified: PAP operated manually, computerized, or through
existing pharmacies. PAP are run through on-site 340 B
pharmacies and as separate programs. Four staffing models
were found: providers, dedicated personal (nurses or program
managers), pharmacy staff and pharmacy faculty in
conjunction with a training program. Common benefits of
PAP included: increasing access to care, improving quality of
care, preventing CHC pharmacy financial loses, and increasing
patient satisfaction. Common drawback included: operating
PAP is complex, time consuming, and costly operations; and
large start-up costs, decreased patient satisfaction due to
inconsistencies with PAP, and concerns with quality of care
and sustainable access. Benefit to cost ratios ranged from
$5.41-$213 for dollar invested, (mean: $78.53, SD: $111.25), with
higher ratios for those processing more medications. Cost to
operate per medication received ranged from $10-$18.92
varying according to how programs were managed.
Conclusions: PAP provide health centers with means to help
patients’ access pharmaceuticals. They run at a cost to health
centers, with most benefits accruing to patients in the form of
medications. PAP run best with dedicated managers and
when they are streamlined into existing operating systems.
The greater the number of PAP processed, the greater the
benefit to cost ratio. They are more economical to operate
through in-house pharmacies, however CHC that started
using PAP prior to obtaining 340 B pharmaceuticals are more
likely to incorporate PAP into their systems than those with
established 340 B pharmacies.
Implications for Policy, Delivery, or Practice: PAP are
valuable adjuvant to CHC to care for the underserved.
However, CHC require financial resources to run these
programs effectively. States should provide financial incentives
to encourage the use of PAP. State and federal grant are
needed to support PAP expansion costs. Finally, as a nation
we need to decide if it is sufficient to rely on multiple voluntary
charitable programs run by private-for-profit organizations to
serve as our Nation’s safety net health care system.
Primary Funding Source: CWF
the publicly insured. These differences across insurance
groups are due to both differences in the age distribution and
the presence of medical conditions conditional on age. In
particular, the uninsured have lower expected expenditures
both because they are younger and because they report fewer
medical conditions. For children, in contrast, health status
appears to be similar among the privately and publicly insured
while the uninsured children appear to be healthier.
Conclusions: Our results are consistent with selection into
health insurance based on health status. Those in worse
health are more likely to enroll on average than those in poor
health. Particular segments of the uninsured population are
characterized by worse health, suggesting that barriers may
exist in obtaining coverage for these individuals. Among
adults, but not children, public insurance appears to cover a
relatively less healthy segment of the population.
Implications for Policy, Delivery, or Practice: Our findings
suggest that researchers should be cautious in making
extrapolations from populations currently enrolled in health
insurance for estimates of the cost of covering the uninsured
because these populations differ based on their underlying
health status. The results also point to high priority segments
of the uninsured population, from the perspective of their
health, in targeting coverage expansions.
Primary Funding Source: No Funding
●The Health Status of the Uninsured
M. Kate Bundorf, Ph.D., Donna MacIsaac, MA
●The Effects of Chronic Illness and Chronic Uninsurance
on Long-term Health Status
Nancy Cheak, MA, Timothy McBride, Ph.D.
Presented By: M. Kate Bundorf, Ph.D., Assistant Professor,
Department of Health Research and Policy, Stanford
University School of Medicine, HRP Redwood Building, Rm
T108, Stanford, CA 94305-5405; Tel: 650.725.0067; Fax:
650.725-2586; Email: bundorf@stanford.edu
Research Objective: The cost of strategies to reduce the
number of uninsured Americans depends on the underlying
health status of the uninsured. Relatively little evidence exists,
however, on the extent to which the uninsured differ from
those with either public or private health insurance in their
health status. In this paper, we investigate the relationship
between health status and insurance status.
Study Design: Using data from the 2-year panel component
of the Medical Expenditure Panel Survey, we develop
estimates of an individual’s expected health expenditures
based on the presence of medical conditions. This measure
of health status allows us to aggregate multiple dimensions of
health into a single index of health status based on the
contribution of medical conditions to health care costs. We
also use these estimates to develop measures of health status
which distinguish between demographic characteristics and
medical conditions in their contribution to expected health
expenditures. Using these measures, we compare the health
status of the privately insured, the uninsured, and the publicly
insured. We also examine differences within insurance groups
based on socioeconomic characteristics and examine the
possibility of underreporting of medical conditions among the
uninsured.
Population Studied: A nationally representative sample of the
under 65 population in U.S. during 1997-2002.
Principal Findings: Among adults, we find that expected
health expenditures among the privately insured are higher
than those among the uninsured and lower than those among
Presented By: Nancy Cheak, MA, Graduate Research
Assistant, School of Public Health- Health Policy and
Management, School of Public Health, 3545 Lafayette Ave.,
Saint Louis, MO 63104; Tel: 314-977-8128; Fax: 314-977-1674;
Email: cheaknc@slu.edu
Research Objective: This study uses a quantitative,
longitudinal analysis of the determinants of health status,
comparing the chronically ill and chronically uninsured to
other groups within the population.
Study Design: Using Michael Grossman’s Demand for
Health Capital Model as my underlying theory, I will
empirically test the hypothesis that persons who are
chronically ill, and who have long spells of uninsurance, are
unable to buy needed health commodities which results in
negative health outcomes. This becomes a cyclical problem in
which poor health increases the need for medical care which is
not adequately accessible resulting in poorer health of the
individual. Data from the 2002-03 Medical Expenditure Panel
Survey (MEPS), a health services and expenditure survey
cosponsored by the Agency for Healthcare Research and
Quality and the National Center of Health Statistics, is used in
this analysis. The Physical Component Summary score (PCS)
of the SF-12 version 2 and a perceived health variable will be
used to measure perceived health status.
Population Studied: The sample frame is drawn from the
National Health Interview Survey representing a sample from
the general civilian non-institutionalized public with oversampling of Hispanic, African American, Asians, and family’s
expected to have incomes below 200% of the poverty line.
The household component of the MEPS is used in this
analysis, and 20,661 adult United States residents completed
the SF12v2 and perceived health items.
Principal Findings: Reliability and validity for the health
status measures, SF12v2 and perceived health status, within
this database has been conducted and adequate reliability and
validity within the 2003 MEPS was observed. This testing was
important because this is the first time in which the SF-12v2
has been used within the MEPS. The PCS was shown to have
perfect dose-response change when the mean group scores
were compared using participants’ chronic condition status.
Initial analysis of the research question supports the
hypothesis that health insurance status has an effect on the
perceived health status of persons with one or more chronic
condition.
Conclusions: Previous research has shown that for the
average person, the presence or absence of health insurance
has a negligible affect on their health. Unfortunately, a
growing proportion of our society does not have the luxury of
good health. These health problems are often caused by
serious health conditions. Improperly treated these
conditions will increase in severity. Likewise the cost to treat
them will increase exponentially. Governmental policy must
be implemented to deter this costly process.
Implications for Policy, Delivery, or Practice: The physical
problems that plague the chronically ill are extremely
burdensome, those that are both chronically uninsured and
chronically ill have their health problems exacerbated by the
lack of insurance and the simultaneous nature of their
disease. Few studies analyze characteristics that makeup this
group and how these characteristics affect their long-term
health. This study will provide a new view of the chronically-ill
and uninsured.
Primary Funding Source: No Funding
●Barriers to SCHIP Enrollment and Renewal in an InnerCity Population
Julia Costich, J.D., Ph.D., Priyanka Srinivasan
Presented By: Julia Costich, J.D., Ph.D., Chair, Dept. of Health
Services Management, College of Public Health, 121
Washington Ave, Lexington, KY 40536-0003; Tel: 859-257-6712;
Fax: 859-257-3909; Email: julia.costich@uky.edu
Research Objective: To identify and classify barriers
encountered by low income parents residing in the 16-largest
US metropolitan area in obtaining or retaining health
insurance for their children.
Study Design: A brief survey was distributed by front desk
personnel to a total of 202 parents of uninsured children at
community health centers. Response options included a
checklist generated from interviews with key informants and
an open text field. Responses were tallied and classified as
reflecting system or knowledge barriers; open text responses
were recorded verbatim. Geographically sensitive responses
were further classified by zip code.
Population Studied: Low-income inner city families.
Principal Findings: Initial SCHIP or Medicaid enrollment
required a face-to-face interview, while coverage renewal
paperwork is sent by the responsible state agency and can be
returned by mail. Nearly 20% of parents stated that they did
not receive renewal information in the mail as required by
state policy and procedure. About 10% were unaware that
their children had lost coverage until they registered at the
health center, and 11% could not provide the income
documents necessary for renewal. When asked what could be
done to make the process easier, 32% suggested sending the
form earlier so that they would have more time to work on it,
34% wanted information about the process beforehand so
that they know what to expect, and 41% wanted to make it
easier to call a caseworker if they had questions during the
process.
Conclusions: The return to in-person interviews for initial
eligibility determination unmasked problems with the mailed
renewal process that had gone undetected because they were
so easily remedied when applications could be mailed.
Barriers to continuity in SCHIP/Medicaid enrollment in this
metropolitan area are mainly systemic: parents have difficulty
because they do not receive the necessary information by mail
in a timely manner or lack access to assistance with
documentation.
Implications for Policy, Delivery, or Practice: Systemic
barriers must be eliminated or mitigated to assure children’s
continuity of coverage.
Primary Funding Source: Primary Care Association
●Expresslane Enrollment in California
Michael R Cousineau, Dr.P.H., Eriko Wada, M.P.P.
Presented By: Michael R Cousineau, Dr.P.H., Director, Keck
School of Medicine, Community Health, 1000 Fremont Dr,
Alhambra, CA 91803; Tel: 626 457-4010; Fax: 626 457-5858;
Email: cousinea@usc.edu
Research Objective: To assess the effects of Expresslane
Enrollment on Medi-Cal enrollment and utilization of MediCal-suported services.
Study Design: Comparative case studies of numbers and
percent of eligible children enrolled into full Medi-Cal as a
result of Expresslane Eligibility in six counties in California
implementing ELE for Medi-Cal enrollment over a three year
period 2003/04 to 2005/06 school years. Overall trends were
measured as were comparisons between outcomes among
the six participting counties. County-specific data (including
size, percent uninsured, presence of a Healthy Kids product,)
were used to explain differences in outcomes across piolot
sites. Measuring changes in school lunch participation in
periods before and after ELE, and betwen ELE sites and non
ELE sites were used to determine the effects of ELE on the
school lunch program.
Population Studied: Uninsured children whose parents sign
consent and who are express enrolled into Medi-Cal;
participating schools and school districts
Principal Findings: In the pilot for year 2, over 3000
potentially eligible children were identified (school lunch
eligible). Of these 13% had signed consent authorizing
schools to forward application to Medi-Cal. Of these nearly
half were already enrolled in Medi-Cal or Healthy Families, and
41% were express enrolled into temporary Medi-Cal;16% were
ineligible. Upon further screening, about 400 children about
one third of those express enrolled were enrolled into
ongoing, regular Medi-Cal. Significant differences in the
number and percent of eligible children enrolled into Medi-Cal
as a percent of eligible children are observed when comparing
the various pilot sites. High Medi-Cal participation rates in
pilot sites, parents fear of public charge and immigration
concerns, and additional Medi-Cal administrative burdens,
and a lack of support staff to assist parents were associated
with low participation rates.No change in school lunch
participation is noted when comparing schools before and
after ELE.
Conclusions: The ELE program is not an effective as a standalone enrollment strategy especially in school districts with
already high Medi-Cal penetration. Still, there appears little if
any danger in decreasing school lunch participation as a result
of the Express lane Eligibility program. Administrative
obstacles in the enrollment and approval process leading to
enrollment, parents’ fear of public charge limit the
effectiveness of the program in improving enrollment.
Implications for Policy, Delivery, or Practice: Linking public
insurance program enrollment to existing benefits program is
best deployed as one of many enrollment strategies. In order
to improve success, administrative obstacles should be
removed, and parents fears of public charge alleviated.
Moreover, Expresslane helps to expose (but does not reduce)
the overall complexity and fragmentation in the health
insurance enrollment system for low income children and
families.
Primary Funding Source: The California Endowment, Blue
Shield Foundation
●Implementation of Project ACCESS for the Uninsured in
Dallas, Texas was Associated with Overall Improvement of
Access to the Emergency Department.
Dan Culica, M.D., Ph.D., Barbara Foster, Ph.D., Nora Gimpel,
M.D., James Walton, DO, Mark DeHaven, Ph.D.
Presented By: Dan Culica, M.D., Ph.D., Assistant Professor,
Management, Policy and Community Health, UTSPH, 5323
Harry Hines Blvd, V8.112N, Dallas, TX 75390; Tel: 214-6481070; Fax: 214-648-1081;
Email: dan.culica@utsouthwestern.edu
Research Objective: One of the main hypotheses of this
project was that utilization of emergency department in a large
inner-city hospital will be lower after the implementation of the
Project ACCESS and the health status and quality of life of the
uninsured patients enrolled in this model of care will improve.
Study Design: A case–control design was used to enroll
patients over 13 months (April 2003-July 2004) at the
emergency department of a large metropolitan hospital in
Dallas. Overall utilization of the emergency department by the
patients enrolled in Project ACCESS and their control group,
and the average length of stay for hospital admissions of the
same patients were measured during the enrollment period
and the 12 month follow-up.
Population Studied: Six hundred and twenty three patients
participated in the study, of which 270 were enrolled for the
Project ACCESS intervention while 353 represented the control
group who followed the routine practice.
Principal Findings: There was a significant decrease in the
number of patients who visited the emergency department in
both groups between the enrollment year and the observation
period. There was a significant greater average length of stay
among the patients enrolled in the Project ACCESS compared
with the control patients during the enrollment year. There
was a significant lower length of stay among patients enrolled
in the Project ACCESS and those in the control group in the
observation year that followed the intervention.
Conclusions: These results provide evidence of the overall
benefits produced by a program of medical care designed and
implemented at local level to assist a population sector with
poor access to health care in a large metropolitan area.
Implications for Policy, Delivery, or Practice: Similar
interventions developed at community level to assist inner-city
population that faces multiple barriers to medical care due to
low socio-economic status create the premises of a
complementary care system that not only improves the health
status of the targeted population but also alleviates the
burden on the entire safety-net system.
Primary Funding Source: CDC
●Extending the Measurement of Bias in Uninsured
Estimates
Gestur Davidson, Ph.D., Gestur Davidson, Ph.D.
Presented By: Gestur Davidson, Ph.D., Senior Research
Associate, Div. of Health Services Research & Policy, Univ. of
Minnesota, 2221 Univ. Ave. S.E. Suite 345, Minneapolis, MN
55414; Tel: 612-625-2339; Email: david064@umn.edu
Research Objective: To estimate the possible downward bias
in estimated rates of uninsured in statewide surveys.
Study Design: We use a random sample of knonwn enrollees
of public programs in the state of PA and survey them and
their family memebers as if they had been selected in a RDD
statewide survey of coverage. We focus on the members of
these families--which contain 1+ members on public
programs--who are not themselves on any public program.
Population Studied: Among these family members not on a
public program, we focus on those who self-report being on a
public program when they are not enrolled, i.e. the False
Positives (FP). And among these FP, we focus only on those
who report no other types of coverage,i.e. (FP(N).
Principal Findings: We provide various estimated lower
bounds for this number of FP(N)s who would be counted as
uninsured were they in a general survey of households "but
for" falsely reporting public coverage. The reasonable range of
these estimates of downward bias in estimated rates of
uninsured is larger than the upward bias contributed by public
program enrollees who fail to report their coverage and report
no other coverage, the so-called False Negatives of the
Medicaid Undercount.
Conclusions: Considering only the combined impacts of
people on public programs and other family members in their
households, we conclude it’s likely that there is a net
downward bias in the estimated percent of the population
without any insurance in the Pennsylvania health insurance
survey.
Implications for Policy, Delivery, or Practice: This analysis
begins to identify and carefully measure alternate sources of
bias in surveys of the uninsured, and by so doing it corrects
the presumption that the Medicaid undercount provides the
only or the largest component of bias in the estimated rate of
uninsured.
Primary Funding Source: RWJF
●Geographic Disparity in Health Insurance Coverage:
Inner Cities versus Outer Metropolitan Areas
Derek DeLia, Ph.D., Dina Belloff, MA
Presented By: Derek DeLia, Ph.D., Assistant Professor/Senior
Research Analyst, , Rutgers Center for State Health Policy, 55
Commercial Avenue, New Brunswick, NJ 08901-1340; Tel:
(732)932-4671; Fax: (732)932-4695; Email:
ddelia@ifh.rutgers.edu
Research Objective: To measure the disparity in health
insurance coverage between inner cities and outer
metropolitan areas (OMA’s) and document factors affecting
the disparity.
Study Design: The New Jersey Family Health Survey (NJFHS)
is used to measure health insurance coverage and
socioeconomic characteristics of NJ residents. Population size
and density criteria are used to distinguish inner city and
OMA’s. Regression decomposition is used to determine the
most important factors behind the geographic coverage
disparity (GCD) defined as the uninsured rate in inner cities
minus the rate in OMA’s.
Population Studied: Children (0-18) and non-elderly adults
(19-64) living in NJ in 2001.
Principal Findings: The GCD for children was 11.9 percentage
points (19.7% minus 7.8%). More than half of this disparity is
explained by lower family income among inner city children.
Two-fifths is explained by the lower likelihood of inner city
children to live with both parents. Although other factors such
as immigration and race/ethnicity also play a role, the GCD for
children is actually smaller than one would expect after
adjusting for geographic differences in socioeconomic
variables. The GCD for non-elderly adults was 19.4 percentage
points (32.5% minus 13.1%). Two-fifths of this disparity is
explained by lower family income in inner cities. One-fifth is
explained by a higher concentration of non-citizen adults in
inner cities. A significant portion (28%) of the GCD for adults
remains unexplained after accounting for geographic
differences in socioeconomic variables. All findings are robust
to alternative criteria used to distinguish inner cities from
OMA’s.
Conclusions: There is a large geographic disparity in health
insurance coverage for both children and non-elderly adults,
which is driven primarily by lower income among inner city
residents. The disparity for children may be somewhat
surprising given the availability of coverage under the State
Children’s Health Insurance Program (SCHIP). However, the
findings suggest that the disparity among children is the result
of much greater socioeconomic disadvantage in the inner
cities, which may work against SCHIP enrollment efforts.
While low income and non-citizen status are important, a
great deal of the GCD for adults remains unexplained. Future
research should investigate whether this part of the disparity is
the result of unmeasured characteristics of adults living in
inner cities or characteristics of the inner cities themselves
(e.g. availability of safety net facilities providing free care).
Implications for Policy, Delivery, or Practice: Previous
research on geographic disparities in coverage is based on
broad rural/metropolitan classifications. This research shows
how these broad classifications can be misleading as there is
significant coverage variation within metropolitan areas. The
predominance of income as a driver of coverage disparities
within metropolitan areas suggests that income-based
subsidies will be an essential part of expanding coverage in
inner cities. Special consideration of family structure may also
be important to maximize the enrollment of inner city children
into SCHIP. The concentration of immigrants in inner cities,
and their importance in driving the GCD, will continue to
present challenges for urban safety net providers as recent
immigrants remain ineligible for most public coverage.
Primary Funding Source: HRSA
●Uninsurance Among Children Whose Parents are Losing
Medicaid Coverage
Jennifer DeVoe, M.D., D.Phil., Lisa Krois, M.P.H., Tina Edlund,
MS, Jeanene Smith, M.D., M.P.H.
Presented By: Jennifer DeVoe, M.D., D.Phil., Postdoctoral
Research Fellow, Department of Family Medicine, Oregon
Health and Science University, 3181 Sam Jackson Park Rd,
Portland, OR 97239; Tel: (503) 494-2826; Fax: (503) 494-2746;
Email: devoej@ohsu.edu
Research Objective: One way to improve children’s access to
health insurance is to expand parental coverage. Less is
known, however, about how termination of parental coverage
affects children. Recently, thousands of adults lost coverage
after Oregon’s Medicaid program (the Oregon Health Plan)
implemented tighter administrative rules and benefit
reductions. This study was conducted shortly after these
cutbacks to examine possible impacts on children’s access to
health insurance.
Study Design: Cross-sectional analysis. Our collaborative
team of researchers created a unique survey instrument to
collect statewide primary data from low-income families about
their current health insurance coverage and their experience
accessing healthcare services for their children.
Population Studied: To gather information about children
eligible for publicly funded health insurance programs, the
sample included all 84,087 Oregon families with children
enrolled in the food stamp program at the end of January
2005. This report presents descriptive data from 2,681
completed surveys. Using administrative demographic data,
we were able to weight all results back to the entire sample
population and control for non-response.
Principal Findings: Among the children in Oregon’s food
stamp population, 10.9% were uninsured, 73% of children had
only public insurance coverage, and 16.1% had private
coverage. More than one-quarter (26.3%) of the children in
the study went without health insurance coverage at some
time during the 12-month period immediately prior to the
study. Low-income children who were most likely to be
uninsured or have coverage gaps were Hispanic; were
teenagers over age 14; were in families at the higher end of the
income threshold; had an employed parent; or had a parent
who was uninsured. Nearly 80% of uninsured children had a
parent without health insurance, compared with less than
20% of privately-insured children (p<0.0001). Fifty percent of
uninsured children lived in a household with at least one adult
who had recently lost coverage under the Oregon Health Plan,
compared with only 40% of children with health insurance
(p<0.0001). Similarly, over 51% of children with a recent gap
in insurance coverage had an adult in the household who lost
Oregon Health Plan, compared with only 38% of children
without coverage gaps (p<0.0001).
Conclusions: Over 10% of children in Oregon eligible for
publicly funded health insurance programs were uninsured,
and over 25% of these children had gaps in insurance
coverage during a 12-month period. Four out of five
uninsured children had an uninsured parent, compared with
just one out of five insured children. Uninsured children and
those with recent coverage gaps were more likely to have
parents who lost Oregon Health Plan coverage after recent
cutbacks.
Implications for Policy, Delivery, or Practice: Although
current fiscal constraints prevent many states from expanding
public health insurance coverage to more parents, states need
to be aware of the impact on children when parents lose
coverage. It is critical to develop strategies to keep parents
informed regarding continued eligibility and benefits for their
children and to reduce administrative barriers to children’s
enrollment and retention in public health insurance programs.
Primary Funding Source: HRSA
●A Tool based on a Model of Personal and Ecologic
Characteristics to Explain Deprivation in US Healthcare
access.
Martey Dodoo, Ph.D., Robert Philips, Jr,, M.D., M.S.P.H.
Presented By: Martey Dodoo, Ph.D., Senior Economist, The
Robert Graham Center, 1350 Connecticut Ave, N.W. Ste 201,
Washington, DC 20036; Tel: 202-331-3360; Fax: 202-331-3374;
Email: mdodoo@aafp.org
Research Objective: To develop a tool for identifying small
area communities and/or populations at risk of health care
access deprivation in the US.
Study Design: There have been many attempts to use
personal characteristics to explain barriers or delays in
accessing healthcare appropriately. There have also been
attempts to use ecological measures like poverty as a nearproxy for health access problems.
In this study we combined these efforts to develop indices of
health access deprivation, or risks of delaying or not getting
healthcare in the US. We used the National Health Interview
Survey (NHIS) to identify individual level predictors of health
care access deprivation, and constructed indices of access
deprivation using logistic and principal component analyses
methods. We geo-coded the individual level data that included
the access deprivation indices, and merged them with 2000
US Census data at block group level. Using multi-level logistic
modeling techniques we undertook pair wise substitution of
Census for NHIS variables that allowed us to determine the
ecologic variables that best predict reported health access
problems in the US. We mapped the small area deprivation
indices and showed how they can be overlaid with health care
provider availability and other statistics.
Population Studied: 2000 US Census data at block group
level and a 2002 NHIS national probability sample of 31,044
adults.
Principal Findings: We identified 4 strong predictors of
health care access deprivation and 6 other predictors, out of
23 potential predictors from the literature. We found that
someone is more likely to be deprived of care, if they are
female, do not own a home, live in a single adult household,
have a functional limitation, smoke, have no health insurance
or are less than 65 years old.
Conclusions: Attempts to use individual level data to model
barriers or delays in accessing health care can be combined
with the use of ecologic characteristics to determine health
care access problems, to identify small areas or populations at
risk of health care access deprivation
Implications for Policy, Delivery, or Practice: This study has
provided a tool that may be used as a basis for local
community assessments, health planning, and to identify
specific communities and/or populations at risk of having
health access deprivation problems or issues.
Primary Funding Source: No Funding
●Michigan Medicaid’s Healthy Kids Dental program:
Assessment of the first 4 years
Tracy Finlayson, Ph.D., Stephen A. Eklund, D.D.S., M.H.S.A.,
Dr.P.H.
Presented By: Tracy Finlayson, Ph.D., AHRQ Postdoctoral
Scholar, School of Public Health, UC Berkeley, 140 E Warren
MC7360, Berkeley, CA 94720-7360; Tel: 510-642-5652; Fax: 510643-4281; Email: tracyf@berkeley.edu
Research Objective: In 2000, Michigan’s Medicaid dental
program initiated Healthy Kids Dental (HKD), a
demonstration program offering dental coverage to Medicaidenrolled children in 37 of its 83 counties. HKD is administered
through the Delta Dental Plan of Michigan (DDPM), using
DDPM-affiliated dentists who are reimbursed at usual
customary rates. This study evaluates trends in children’s
access to dental care, treatment patterns, dentist participation,
and cost in the first four years of HKD.
Study Design: DDPM dental claims were obtained for
children in the 37 HKD counties and enrollment and
utilization data were analyzed. HKD was originally
implemented in 22 counties on May 1, 2000, and expanded to
another 15 counties on October 1, 2000. All trends were
examined for 12-month periods for the 22 and 15 county
groups separately over time between 2000 and 2004.
The proportion of children by age enrolled and utilizing dental
services in each 12-month period reflected trends in access to
care. Differences in utilization patterns by length of
enrollment were also investigated. Children with two or more
cleanings or topical fluoride treatments, two common
preventive procedures, were examined to explore whether or
not they likely had a dental home and went to the same
provider for all of these services. The total number of dentists
participating in HKD was also counted, and the proportion of
in-county providers tabulated. The average travel distance
between children and providers was approximated using a
GPS methodology to calculate distance between ZIP code
centroids for each visit. Total costs and the distribution of
payment for different select major procedure groupings
(diagnostic/preventative, restorative, endodontics, and
surgical) were also calculated.
Population Studied: HKD enrolled children aged 0 to 20 in
Michigan’s 37 HKD counties were included in this study.
Principal Findings: In the first year, children’s backlog of
dental needs appeared to be treated. Since the beginning of
the program, access to care has continued to improve and
more children are receiving dental services each year. The
largest increase in utilization was observed between the first
and second years of the program. Children have a high
probability of having a dental visit if enrolled, and the
proportion of continuously enrolled children has been
growing. The number of dentists providing care has been
increasing and children continue to receive needed services
from local providers close to home (average travel distance
was consistently 13-15 miles). At least 40% of HKD children
likely have a dental home and more children appear to be
entering regular recall patterns. Costs have increased each
year, attributable to more children receiving care and a
customary rate of reimbursement for services.
Conclusions: HKD has been successful in increasing access
to dental care for the child Medicaid population in the
demonstration counties. The program has grown between
2000 and 2004; more children have enrolled each year, and
more local dentists are participating in the program and
integrating these children into their practices and providing
comprehensive treatment.
Implications for Policy, Delivery, or Practice: HKD can
serve as a template for other states reforming their Medicaid
program’s dental component.
Primary Funding Source: NIH
●Step by Step: Local Coverage Expansion Initiative 2005
Evaluation Findings
Annette Gardner, Ph.D., M.P.H., Patricia Mintz, M.B.A.
Presented By: Annette Gardner, Ph.D., M.P.H., Academic
Specialist, Institute for Health Policy Studies, University of
California, San Francisco, 3333 California Street, Suite 265, San
Francisco, CA 94143; Tel: (415)514-1543; Fax: (415)476-0705;
Email: annette.gardner@ucsf.edu
Research Objective: In 2005, the California HealthCare
Foundation (CHCF) funded Year 2 of Step by Step: Local
Coverage Expansion Initiative to increase the capacity of local
organizations to expand insurance coverage for low-income,
uninsured Californians. The goals of the program are to: 1)
Foster development and implementation of local health
insurance programs; 2) Encourage efforts to increase
enrollment in local and state public insurance programs; and,
3) Increase the number of insured Californians. Evaluation
research objectives focused on achievement of the broader
goals or outcomes resulting from the Step by Step program,
specifically: increased grantee and stakeholder knowledge of
the scope of the problem and potential solutions;
development and maintenance of critical partnerships; the
ability to identify and secure new funding; actual and
anticipated enrollment gains for children and adults in new
and existing programs; and changes in grantee capacity to
design and launch an insurance program.
Study Design: The study design for the evaluation of the Step
by Step Program focused on the assessment of individual
achievement of grantee objectives using grantee mid-point
and final reports and assessment of overall program
achievement of key short-term outcomes using end-point
interviews. Additionally, grantees completed a pre/post
survey on specific skills in planning and implementing an
insurance coverage initiative. Last, grantees provided
information on 2005 actual and 2006 enrollment in existing
and new insurance programs, as well as 2005 actual and 2006
estimated funding secured that might be due to their Step by
Step participation.
Population Studied: Thirteen grantees representing local
coalitions, agencies, local governments and health plans were
awarded grants to plan or implement a coverage expansion in
2005. Of that group, six were awarded one-year planning
grants: four for projects focused on expanding coverage for
children; two for projects focused on expanding coverage for
adults. The remaining seven grantees focused on key
implementation activities: six for projects focused on
launching a specific insurance program for children; one for a
coverage program focused on adults. Grantees were diverse in
geographic focus, target population and the lead agency.
Principal Findings: The findings on individual and collective
grantee achievements point to the continued success of the
Step by Step program in expanding coverage for children and
adults under diverse (and often adverse) conditions. Planning
grantees successfully positioned themselves to move forward
with implementation of their designs, e.g., 3 grantees will be
funded for implementation during Year 3 of the Step by Step
program. Implementation grantees, particularly those
focusing on children, have or will shortly launch their
respective coverage programs, achieving significant
enrollment gains in public and private insurance programs.
Adult grantees hold great potential for new models of funding
and partnerships. However, it hasn’t been easy. Grantees of
all types have had to contend with a variety of operational and
external challenges while weighing their choices.
Conclusions: The findings from Years 1 and 2 of the Step by
Step program point to the importance of providing technical
assistance to localities to reduce the barriers to care for the
uninsured. Similar to 2004, significant uncertainty persists in
terms of local funding and the possibility of statewide
coverage. However, the apparent capacity and commitment
to undertake local coverage expansions, coupled with
partnerships with the state and significant commitment from
private funders, bodes well for local coverage expansions in
the near future.
Implications for Policy, Delivery, or Practice: The
implications of these local coverage expansions for
stakeholders interested in expanding coverage are two fold: 1)
achieving statewide coverage based on these local efforts, a
goal sought by many stakeholders and advocates, presents
some challenges, such as recognizing differences in target
populations, provider capacity and political commitment; and
2) the insurance and funding gains, while significant at the
local level, may collectively fall short of the larger demands for
coverage. Similarly, the implication for funders and others
desiring to further local coverage expansions is to proceed
cautiously with a “one size fits all” approach, particularly for
adult expansions. Additionally, grantees benefit greatly from a
“hands on” grant program that holds them accountable to
their respective objectives and provides assistance as the need
arises.
Primary Funding Source: California HealthCare Foundation
●Expanding Policy Advocacy Capacity: Results from the
Clinic Consortia Policy and Advocacy Program Evaluation:
2001-2004
Annette Gardner, Ph.D., M.P.H., Claire Brindis, Dr.P.H., Sara
Geierstanger, M.P.H., Coline McConnel, MA, Melissa MartinMollard, M.S.W., Nadine Chabrier, BA
Presented By: Annette Gardner, Ph.D., M.P.H., Academic
Specialist, Institute for Health Policy Studies, University of
Californa, San Francisco, 3333 California Street, Suite 265, San
Francisco, CA 94143; Tel: (415)514-1543; Fax: (415)476-0705;
Email: annette.gardner@ucsf.edu
Research Objective: In 2001, The California Endowment
awarded more than $9 million to fifteen California regional
community clinic associations and four statewide clinic
organizations to strengthen the role and capacity of consortia
to support the management, leadership development, policy
and systems integration needs of community clinics. The
three year grant supported specific activities related to policy
advocacy or activities that mobilize resources to support a
policy issue or create a shift in public opinion, technical
assistance, media advocacy, as well as shared services.
Eighteen grantees were refunded for three years in 2004 to
undertake or continue a similar set of activities. A unique
funding opportunity directed to a relatively unknown grantee
population, our research objectives were to assess the
effectiveness of key policy advocacy activities, such as
educating policymakers and media advocacy and the
achievement of short-term outcomes, such as increased
funding to California clinics and their target populations and
policy outcomes to increase access to care for low-income
populations.
Study Design: We are using a case-study approach to identify
differences and similarities among grantees and longitdudinal
approach to assess achievement of program outcomes in the
aggregate. Using a logic model framework, we administered
a combination of quantitative and qualitative instruments to
the 19 grantees to measure grantee processes and outcomes
from 2001-2004. The UCSF Team collected longitudinal data
from grantees on cross-site indicators, such as type, number
and effectiveness of policy advocacy activities and funding to
clinics and consortia, and consortia partnerships. Second, we
conducted interviews and focus groups with the targets and
beneficiaries of grant-funded activities. To assess changes in
policymaker awareness of the grantees and clinics as well as
their activities, events, and issues, we administered a 15minute Stakeholder Awareness Survey to over 70 policymakers
and community leaders in 2003. In 2004, the UCSF Team
readministered the Stakeholder Awareness Survey to 43 state
and local policymakers and community leader perceived to be
less familiar with consortia and/or clinics but were
nonetheless considered important stakeholders in California’s
health care safety net. To assess consortia capacity in
engaging in media advocacy, the UCSF Team interviewed 17
media representatives and 6 media consultants in 2004. Last,
to assess the benefits of grant-funded activities to clinics and
their target populations, we interviewed up to 3 member
clinics per grantee (for a total of 47 clinics) in 2002 and
conducted a focus groups with 11 clinic Executive Directors in
2004. All data was aggregated, tabulated and crosscutting
themes were identified.
Population Studied: Clinic consortia are membership
organizations for primary care clinics and related safety net
providers. (There are approximately 768 primary care clinics
in California that serve over three million low-income and
uninsured Californians.) California is unique in that it has 19
community clinic consortia, with the oldest dating back to
1969 and the most recent launched in 2001. Consortia are
flexible organizations that help individual clinics meet the
needs of their clinic populations, providing a unified voice in
the policymaking arena and offering economies of scale for
business and program shared services.
Principal Findings: The results of our assessment of key
Program outcomes, include:1) Increased policy advocacy on
behalf of clinics and their target populations. For example, the
precent of policy advocacy activities undertaken by grantees
increased from 73% in 2002 to 84% in 2004; 2) Increased
clinic financial stability. For example, 17 grantees secured $248
million on behalf of clinics and consortia from 2001 to 2003
(90% went to clinics); 3) Increased policymaker awareness
and support. For example, respondents from the two survey
groups were familiar and supportive of clinic policy issues
(72%); 4) Policy “wins” benefit clinics and their target
populations. For example, grantees were involved with 58
pieces of legislations at the federal and state level from 2001
to 2003. of these, 15 (30%) federal policies were passed and
26 (60%) state bills were passed; 5) Member clinics
appreciate consortia contributions. For example, grantee
policy advocacy viewed as increasingly indispensible,
increasing ability of clinics to influence policy; 6) Consortia
develop new partnerships. For example, grantees developed
and nurtured diverse partnerships, such as partnerships
among member clinics, partnerships between member clinics
and non-clinic organizations, and partnerships among
grantees; 7) Strengthened clinic operations. For example,
clinics and grantees report cost savings and revenue
generation. The findings indicate that clinic consortia are
achieving many Program outcomes and they are an
increasingly important and credible voice on behalf of clinics
and the populations they serve. Additionally, these activities
contribute to longer term outcomes of increased access to
care and improved client health status.
Conclusions: The Clinic Consortia Policy and Advocacy
Program represesents a unique funding opportunity,
supporting policy advocacy activities that would not be funded
otherwise. The results are encouraging at two levels: funding
for policy advocacy activities can result in benefits to clinics
and their target population and the Program played a critical
role in expanding clinic consortia capacity and contributing to
the sustainability of these activities. These achievements are
remarkable given the many challenges that grantees have
faced in California, particularly decreased funding to counties
and the state budget shortfall. In all likelihood, the threats to
community clinic expansions will persist, including potential
cuts to the Medi-Cal program that could trigger significant
revenue losses to clinics. Also, some of the program activities
(such as quality improvement and media advocacy) may be
more difficult to implement fully because clinic needs and
resources vary considerably, and these resources may be more
constrained in the future. However, there are policy
opportunities in the political arena at the federal, state and
local levels, as well as opportunities for funding diversification
through new partnerships and programmatic expansions.
Implications for Policy, Delivery, or Practice: The
implications for policymakers and associations (or networks)
are significant. Increasingly, funders are supporting policy
advocacy activities undertaken by diverse grantees. Policy
advocacy activities are proving useful for expanding local, state
and federal support for key policy issues. For example, UCSF
evaluation findings indicate that state-level clinic grant
programs were expanded or maintained by consortia in spite
of a weakening economy and state budget. In an era of
decentralized decision-making and increased grassroots
responsibility for addressing the needs of California’s
vulnerable populations, clinic consortia have great potential
for mobilizing resources and participating in policymaking in
ways that are beyond the means of many individual clinics.
Second, this funding approach and the activities undertaken
by grantees are applicable to other settings and membership
organizations. The results—expanded policy advocacy—
speaks to the opportunities for increased representation in the
policymaking process. For researchers, the evaluation
provides some important lessons and tools in conducting a
multi-site evaluation and developing applicable outcomes and
measures.
Primary Funding Source: The California Endowment
●Welfare Reform, Changes in Insurance Coverage, and the
Timing of Prenatal Care Initiation
Norma Gavin, Ph.D., E. Kathleen Adams, Ph.D., Willard G.
Manning, Ph.D., Cheryl Raskind-Hood, Ph.D., Matthew Urato,
MA
Presented By: Norma Gavin, Ph.D., Senior Research
Economist, , RTI International, 3040 Cornwallis Road,
Research Triangle Park, NC 27709-2194; Tel: (919) 541-6432;
Fax: (919) 990-8454; Email: gavin@rti.org
Research Objective: Welfare reform had the unintended
effect of decreasing health insurance coverage among lowincome women of child-bearing age. Thus, in the postreform
era, more low-income women may be uninsured prior to
pregnancy, enroll in Medicaid later in their pregnancies, and
delay initiating prenatal care (PNC). Welfare reform also
restricted welfare tenure and imposed work requirements and
sanctions for non-compliance, thereby potentially increasing
income and time barriers to PNC. This study investigates the
impact of welfare reform on prepregnancy insurance coverage
and first trimester PNC initiation among pregnant women
financially eligible for Medicaid.
Study Design: We used data for 1996 through 1999 from the
Pregnancy Risk Assessment Monitoring system for eight
states (Alaska, Florida, Maine, New York, Oklahoma, South
Carolina, Washington, and West Virginia). We tested the
endogenity of Medicaid and private insurance coverage in the
model for first trimester PNC initiation and estimated a twopart logistic model of prepregnancy insurance coverage and
first trimester PNC initiation. The impact of welfare reform
was measured through the coefficients of prepregnancy
insurance coverage and an interaction term for the postreform
period and welfare-related eligibility. We compared the
estimates from the two-part logistic model with a simple
logistic model, ordinary least squares, and two-stage least
squares models of first trimester PNC initiation.
Population Studied: We defined the target group affected by
welfare reform as welfare-related Medicaid eligible women and
identified them as single women with children and family
incomes equal to or less than the state’s prereform welfare
level. We defined the comparison group as expansion-related
Medicaid eligible women, which we identified as all other
women with family incomes under 185% of the federal poverty
level.
Principal Findings: We found welfare reform to have a
significant negative impact on prepregnancy Medicaid
coverage but no significant impact on private insurance
coverage prepregnancy. Private insurance coverage prior to
pregnancy was endogenous to the equation for first trimester
PNC initiation but Medicaid coverage prepregnancy was
exogenous. Estimates of the effect of a reduction in Medicaid
coverage on PNC initiation was consistent over the single and
two-stage models, showing a reduction of approximately 10
percentage points in the percentage of welfare-related
Medicaid eligible women initiating PNC in their first trimester.
We found no evidence of an effect of welfare reform on first
trimester PNC coverage beyond the effect on prepregnancy
coverage.
Conclusions: Welfare reform had an adverse effect on the
attainment of the Healthy People goal of 90% of all pregnant
women initiating PNC in the first trimester.
Implications for Policy, Delivery, or Practice: Offering lowincome women Medicaid coverage once they become
pregnant is not sufficient to attain national goals for PNC use
and thereby reduce maternal and infant morbidity and
mortality. Better coverage of women prior to pregnancy and
better outreach to eligible women are needed.
Primary Funding Source: RWJF
●Patient Perceptions of a Community-Based Care
Coordination System
Nora Gimpel, M.D., Alice Marcee, DVM, MS
Presented By: Nora Gimpel, M.D., Assistant Professor,
Family and Community Medicine, UTSouthwestern Medical
Center, 6263 Harry Hines Blvd, Dallas, TX 75390; Tel: 214 648
0768; Fax: 214 648 1307;
Email: nora.gimpel@utsouthwestern.edu
Research Objective: The efficient management of a
community’s health needs is the role of a community health
worker (CHW). This role for a community member to act as a
case manager is common in developing countries. CHWs
serve as the link between a healthcare system and an
individual’s needs. They contribute to the continuity and
quality of healthcare for individuals within a community. This
study is a qualitative evaluation of the impact of CHWs in a
case management model designed to provide access to
healthcare services to uninsured low-income patients. It
evaluates patient perceptions of the effect of CHWs on their
lives and on their ability to independently manage their health
needs.
Study Design: Focus groups were designed to evaluate three
areas: patient empowerment, health education, and the
healthcare system. The community-based program selected
for this study is Project Access (PA). Three different samples
of patients were selected from the primary components of the
program: diabetes, depression and social services.
Population Studied: Ninety-five adults receiving services
through the program were invited to participate in the focus
groups. Seventy three percent were contacted and 35.7 %
(n=25) attended the focus group sessions.
Principal Findings: Interaction with CHWs proved to be an
invaluable asset in learning how to navigate the health care
system and in obtaining appointments. In terms of
empowerment, participants considered the assistance they
received from the CHWs allowed them to better care for
themselves. In addition to the emotional and psychological
support, patients received very practical help such as
assistance with transportation and language translation.
However, patients with diabetes stated that receiving more
specific education on self management would improve their
capability in managing their health problems. Whereas some
patients in the depression group had trouble coming into
contact with their CHW, others had no problems and
maintained good communication with their CHW. In
exploring expectations, all participants were most grateful for
the services they received from PA. They expressed the feeling
that through the CHWs, PA provides medical health services
as well as support for problems not directly related to their
physical health.
Conclusions: This study suggests that CHWs in a case
management model results in improvement in patient
comprehension of health issues, in patient navigation through
a health care system, and in the ability of patients to
independently manage health issues.
Implications for Policy, Delivery, or Practice: Efforts to
provide healthcare services to uninsured, low-income
populations, not otherwise eligible for governmental
assistance, should be coordinated through CHWs serving as
case managers. It is also suggested from the work that
patient input should be routinely assessed as both a way to
evaluate program services and optimize patient
empowerment. It is widely accepted that health care resources
are limited, and this especially pertains to community efforts.
CHWs build relationships between patients, healthcare
providers, and community members which improve the
effectiveness of health services delivered. Providing health
services to underserved populations must include individual
members of the population as stakeholders for the efficient
delivery of limited healthcare resources.
Primary Funding Source: CDC
●The Effect of Care Seeking on Transitions to Medicaid or
SCHIP
Mary Harrington, M.P.P., Ph.D. candidate
Presented By: Mary Harrington, M.P.P., Ph.D. candidate,
Deputy Director, Economic Research Initiative on the
Uninsured, 555 South Forest, Ann Arbor, MI 48104; Tel: (734)
936-1302; Email: mehn@umich.edu
Research Objective: To determine whether uninsured
children eligible for Medicaid or SCHIP should be considered
insured because they will become enrolled when they seek
care.
Study Design: Multiple panels of linked child-parent data
from MEPS, 1998-2002 are used to model the effect of
presenting for care on transitions from uninsured to insured
among low-income children. Because comparisons of
children who do and do not present for care is problematic
due to the potentially endogenous relationship between
enrollment and care seeking, the analysis uses an
instrumental variables approach. An accident indicator
variable is used to instrument for presenting for care to
identify the effect of care on transitions from uninsured to
insured. Comparisons are made between Medicaid or SCHIP
eligible but uninsured children who do and do not have
accidents during the study period. The analysis controls for a
variety of other factors known to influence enrollment,
including changes in parental employment and marital status,
and various demographic indicators.
Population Studied: The analysis uses monthly data on 4
cohorts of uninsured eligible-but-unenrolled children (roughly
700 children per cohort). Demographic, coverage, condition
and selected utilization data for each child are linked with
parent demographic and employment-related information.
Principal Findings: Preliminary results indicate that care
seeking does not have a significant effect on transitions from
uninsured to insured, nor more specifically on transitions
from uninsured to Medicaid or SCHIP, among eligible-butunenrolled low income children.
Conclusions: Some have argued that uninsured children who
are eligible for public programs should not be counted in the
pool of the uninsured because they can apply for coverage and
become enrolled when they present for care. This argument is
made in particular about children who are eligible for
traditional Medicaid because that coverage extends
retroactively to the three month period prior to when an
application is made. Others argue that we should still be
concerned about eligible-but-unenrolled children because they
are less likely to seek out care, especially care that is more
discretionary. Findings from this study suggest that many
uninsured children who are eligible for public coverage are not
becoming insured when they present for care, leaving them
vulnerable to negative effects of lacking coverage similar to
other uninsured groups. Prior research has shown that
children with some form of coverage are more likely to utilize
care, particularly preventive care, have fewer access problems,
and have fewer unmet health care needs.
Implications for Policy, Delivery, or Practice: Policies to
expand coverage for the uninsured should not ignore the
needs of the substantial number of low income children who
are uninsured despite being eligible for public coverage.
Outreach and enrollment assistance efforts to increase the
take up of public coverage among eligible families should be
strengthened.
Primary Funding Source: RWJF
●Toward Universal Child Coverage in Los Angeles County-Early Findings from the Healthy Kids Program Evaluation
Ian Hill, M.P.A., M.S.W., Brigette Courtot, BA, Anna Sommers,
Ph.D., Josh McFeeters, M.P.P., Embry Howell, Ph.D.
Presented By: Ian Hill, M.P.A., M.S.W., Principal Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street, NW, Washington, DC 20037; Tel: 202/261-5374; Fax:
202/223-1149; Email: ihill@ui.urban.org
Research Objective: Numerous counties in California have
developed Children’s Health Initiatives (CHI) with the intent
of providing universal health coverage to children. The
Healthy Kids Program in Los Angeles County, funded primarily
by tobacco tax revenues and philanthropic donations, is by far
the largest CHI in the state, targeting children in families living
below 300% of poverty who are ineligible for Medi-Cal and
Healthy Families (California’s SCHIP). This four-year
evaluation is assessing the implementation and impacts of
the program on children’s coverage, access to care, and health
status.
Study Design: Begun in May 2004, the evaluation comprises
multiple qualitative and quantitative components, including:
case studies of implementation; focus groups with parents;
monitoring of administrative outreach, enrollment, and
utilization data; analyses of the effects of Healthy Kids on
uninsurance and Medi-Cal and Healthy Families enrollment;
and longitudinal household surveys of enrollees to assess
impacts on children’s access to and use of care, and health
status.
Population Studied: Children in the Los Angeles Healthy Kids
Program
Principal Findings: Because of the program’s eligibility rules,
Healthy Kids primarily serves a population of undocumented
immigrant children. Since its inception in July 2003, the
program has enjoyed the strong support of a broad range of
key stakeholders in Los Angeles County. A large number of
community-based organizations conduct intensive, culturally
appropriate outreach and hands-on enrollment assistance
with families in a wide array of settings to enable them to
obtain coverage under all available programs. This approach
is apparently effective, as it has helped over 45,000 children
obtain Healthy Kids coverage in just two years. Case studies
and focus groups with parents suggest that the program’s
application process is simple, that the benefit package (based
on Healthy Families) is meeting the needs of enrolled
children, that the managed care delivery system is affording
good access to care, and that sliding-scale premiums and
copayments are not posing barriers to enrollment or service
use. Parents of children with special health care needs have,
however, indicated that multiple copayments do create some
financial burden. Early program data suggest low utilization
rates, however, measures are confounded by the likelihood
that enrollees are also obtaining services under Emergency
Medi-Cal and the Child Health and Disability Program.
Preliminary results from the first household survey will be
available in June 2006 and will report on whether Healthy Kids
reduced unmet need for health and dental care, increased
access to care, and improved utilization.
Conclusions: Early implementation of Healthy Kids has been
quite successful. Qualitative findings and program
administrative data indicate that the program is effectively
targeting and serving a population of undocumented
immigrant Latino children that have been shown to be
particularly vulnerable and at risk.
Implications for Policy, Delivery, or Practice: Early evidence
suggests that a SCHIP-like program, free of “public charge”
stigma, providing broad benefits and utilizing communitybased, culturally-appropriate outreach and health care
providers can succeed in extending comprehensive coverage
to uninsured, largely undocumented children.
Primary Funding Source: First 5 LA and The California
Endowment
●A Tale of Two PPOs: Competitive Strategy and Prior
Insurance Choices of New Enrollees
Richard Hirth, Ph.D., Kyle Grazier, Ph.D., Michael Chernew,
Ph.D., I-Cha Lee, MS, Arthur Hong, BS, Edward Okeke, M.D.
Presented By: Richard Hirth, Ph.D., Associate Professor,
Health Management and Policy, Univ. of Michigan School of
Public Health, 109 S. Observatory, Ann Arbor, MI 48109-2029;
Tel: (734)936-1306; Fax: (734)764-4338; Email:
rhirth@umich.edu
Research Objective: Preferred Provider Organizations (PPOs)
have become the dominant employer-sponsored plan type,
growing from 11% of enrollment in 1988 to 55% in 2004.
Initially, PPO enrollment growth coincided with growth of
other forms of managed care, coming at the expense of feefor-service (FFS) plans. Commonly it was felt that PPOs were
a transition product leading individuals to stronger forms of
managed care. However, since 1999 PPO growth has come at
the expense of other forms of managed care, calling the
transition product interpretation into question. We use a
natural experiment at the University of Michigan (UM) to
explore the impact of PPO availability on the share of other
plan types.
Study Design: In 2005, UM offered PPOs for the first time.
Two PPOs were offered by vendors who offer other plans to
UM employees. Vendor A also offers a FFS plan that, like the
national experience, has lost most of its membership in this
group over the past decade. Vendor B also offers HMO and
point-of-service (POS) plans, the sorts of plans recently losing
enrollment to PPOs. We complement plan-level analyses with
an employee-level, multinomial logit model of the choice of a
particular PPO relative to a non-PPO plan.
Population Studied: UM employees at all 3 campuses eligible
for benefits in both 2004 and 2005 (n=23,865). Employees
were offered 6 plans from 5 vendors in 2004. These plans
remained available in 2005 along with the new PPOs.
Principal Findings: Overall, 3.1% of enrollees chose Vendor
A’s PPO in 2005 and 4.8% chose Vendor B’s. Less than half
(45.7%) of A’s PPO enrollment was “cannibalized” from its
own FFS offering while the vast majority (84.3%) of B’s PPO
enrollment was cannibalized from its other plans (64.4% from
POS and 19.9% from HMO). A’s share of UM enrollment in
its products rose from 4.3% to 5.2% following introduction of
the PPO. B’s share increased from 68.4%to 70.7%.
Employee-level analysis revealed that female employees and
those previously enrolled in FFS or POS were more likely to
choose either PPO. Relative to those choosing a non-PPO
plan, enrollees in A’s PPO were older and more likely to cover
dependents, have higher compensation, and reside outside
the main campus’ county, and be employed outside the health
system. B’s PPO enrollees were younger and more likely to
reside in Ann Arbor.
Conclusions: PPO enrollment drew from both FFS and
HMO/POS. Selection of each plan was consistent with a
model that the unique provider networks matter. There is no
evidence that the plans were simply vehicles to transition
people to more managed products.
Implications for Policy, Delivery, or Practice: Because PPOs
drew substantial enrollment from more managed plans, even
after controlling for a range of factors at the micro level, the
interpretation that these plans are merely transition products
is likely incorrect. Future visions of the health insurance
market must recognize the salience of this insurance form and
policy makers must recognize that offering PPOs in public
programs such as Medicare may not simply transition people
to HMOs and may actually have the opposite effect.
Primary Funding Source: AHRQ
●Covering more Lives by Improving the Public Safety Net
Jennifer Houlihan, M.P.H.
Presented By: Jennifer Houlihan, M.P.H., Director of
Research and Planning, Research and Planning, Health Care
District of Palm Beach County, 324 Datura Street Suite 401,
west palm beach, FL 33401; Tel: 561-659-1270; Fax: 561-6594620; Email: jhoulihan@hcdpbc.org
Research Objective: To understand the challenges and
benefits of designing and implementing a distinct,
comprehensive safety-net program outside the realm of the
traditional hospital and public health clinic setting.
Study Design: Data analyis will be presented that highlights
trends in demographics, medical trends, and costs of program
membership over a ten year period layered with the impact
changes in the Medicaid and Medicare programs have had on
respective program members. Case examples.
Population Studied: 20,000 + membership pool of safety-net
program. Confined to residents of Palm Beach County.
Principal Findings: Will present trends in demographics,
medical trends, and costs of members to the provider over a
ten year period.
Conclusions: The issue of health insurance coverage is
essentially a local problem subject to demographic and
employment trends unique to each community; solutions are
also local.
Implications for Policy, Delivery, or Practice: Defines the
structure of a public safety-net system, including the benefit
structure, which meets the needs of the uninsured.
Primary Funding Source: No Funding
●A New Uninsured Population: Retirees Under Age 65 at
Risk of Losing Health Coverage
Paul Hughes-Cromwick, BS, MA, ABD, Charles Roehrig, Ph.D.
Presented By: Paul Hughes-Cromwick, BS, MA, ABD, Senior
Analyst, Health Solutions Division, Altarum Institute, 3520
Green Court, Ann Arbor, MI 48105; Tel: (734)302-4616; Fax:
(734)302-4994; Email: paul.hughes-cromwick@altarum.org
Research Objective: Develop a profile of early retirees with
insurance coverage granted as a retirement benefit from a
previous employer; estimate the subset at risk of losing
coverage because of sponsor financial distress; and describe
the policy implications if such losses occur.
Study Design: We refer to individuals who retire prior to
Medicare eligibility, and depend on health insurance from a
previous employer, as early retirees. Many large employers,
public and private, have accumulated substantial numbers of
early retirees and are struggling to meet the resulting financial
obligations. Delphi’s bankruptcy exemplifies a threat to retiree
security – the potential loss of health insurance. We estimate
the number of individuals dependent upon early retiree
coverage using the Current Population Survey (CPS), and
develop health and health-care related descriptors for this
group using the Medical Expenditure Panel Survey (MEPS)
and Health and Retirement Survey (HRS). The subset at
severe risk of losing coverage is estimated through
examination of financial statements using the Security and
Exchange Commission’s EDGAR system. These statements
include legacy costs broken out by pensions and other postemployment benefits – largely healthcare liabilities. These
data allow us to approximate the numbers of persons covered
and also include information on the financial health of the
sponsor. A macroeconomic health model we have developed
estimates the potential impact on health care utilization,
uncompensated care, cost shifting to commercial premiums,
and provider incomes.
Population Studied: This is a national study of early retirees
estimated to be at risk of losing health insurance and possibly
having pensions reduced. Early retirees are predominantly
aged 55-64 and the critical subset involves those whose
previous employers are financially stressed.
Principal Findings: This research is partially complete and is
being internally funded. The number of early retirees aged 5564 who receive health coverage from a former employer or
union is approximately 3.6 million. The per capita needs of
this population are roughly 1.7 times that of the currently
insured population. Thus, one million newly uninsured early
retirees would increase the percentage of uninsured by about
2.2% (from 47 million), but on a needs-adjusted basis the
increase would be about 3.7%. Timely research is continuing
on the numbers and characteristics of those at risk for losing
coverage and the expected impact on utilization, health status,
uncompensated care, and potential increase of commercial
premiums through cost shifting.
Conclusions: Wages can be adjusted to compensate for
current worker benefits, but not for retirees. These legacy
costs directly displace investment and profits, making
companies globally uncompetitive. Legacy costs also decrease
the ability of states and localities to maintain core programs.
Thus, early retirees are at risk of losing coverage. This has the
potential to increase the ranks of the uninsured with a
disproportionate effect on access and utilization due to the
relative age of this population.
Implications for Policy, Delivery, or Practice: Rising
premiums and stagnant wages have resulted in increasing
numbers of uninsured in this country. Sudden loss of
coverage for early retirees could result in a quantum leap in
this problem.
Primary Funding Source: Internal Funding
●Health Care Access in Three Nations: Canada, Insured
America, and the Uninsured America
Jae Kennedy, Ph.D., Steve Morgan, Ph.D.
Presented By: Jae Kennedy, Ph.D., Associate Professor,
Health Policy and Administration, Washington State
University, POB 1495, Spokane, WA 99210; Tel: (509)368-6971;
Email: jjkennedy@wsu.edu
Research Objective: To assess variation in health access and
utilization by nationality and insurance status.
Study Design: Secondary analysis of the 2002/2003 Joint
Canada/US Survey of Health (JCUSH), a cross-national
household survey conducted by the National Center for Health
Statistics and Statistics Canada.
Population Studied: Weighted prevalence rates were
estimated for Canadians (sample n=3,503), currently insured
Americans (sample n=4,673), and currently uninsured
Americans (sample n=510).
Principal Findings: Uninsured Americans are more likely to
report unmet health care needs than insured Americans or
Canadians (35.8% vs. 10.4% vs. 10.7%, P<.001). Among
insured (40.2%) and uninsured (84.4%) Americans, cost was
cited as the main reason for not receiving needed care, while
Canadians with unmet needs were most likely to cite long wait
times (32.5%). Uninsured Americans are less likely to have a
regular physician than insured Americans or Canadians
(39.8% vs. 84.5% vs. 84.9%, P<.001), and more likely to not
fill a prescription due to cost (28.2% vs. 7.7% vs. 5.1%,
P<.001).
Conclusions: The fact that a substantial number of Canadians
and Americans report access difficulties and dissatisfaction
with the health care they receive affirms McGlynn’s
observation that, at least from the consumer’s perspective
“there is no perfect health system.” However, despite
significant differences in the financing and administration of
their health systems, most Canadians and Americans with
health insurance are able to get the care they need. In
contrast, this analysis indicates that approximately one in
three uninsured Americans report unmet health care needs.
Implications for Policy, Delivery, or Practice: The most
important difference between insured Americans and
Canadians is that the latter group is guaranteed access to
health care regardless of age, employment, income, or
insurability. Due to increasing private insurance costs and
changing labor-markets, an increasing number of Americans
are losing their health care insurance. In this sense, uninsured
America is the fastest growing, as well as most vulnerable, of
the three nations studied.
Primary Funding Source: No Funding
Principal Findings: A majority of job endings, among both
those who leave and lose jobs, involve workers who do not
have own ESI through the job that ended. Among those who
do have own ESI, fewer than one in five (17.1 percent) of their
job transitions lead to becoming uninsured. For those who
have own ESI, losing a job poses a greater risk of losing health
insurance than changing jobs. Those who lose their jobs are
nearly twice as likely to lose coverage and become uninsured
as those who leave a job to take another job (24.9 percent of
job losers v. 13.4 percent of job to job movers.) However, job
to job movements are more common than job losses among
those who have own ESI. The higher risk of losing coverage
associated with job loss thus translates into a much smaller
gap in what preceded losing coverage: 41 percent of those
who lost own ESI lost their health insurance coverage when
they lost a job, while 32 percent lost own ESI when they moved
from job to job. While fear of health insurance loss ("job
lock") may keep some workers from changing jobs, other
workers move and experience loss of own ESI. More than one
in ten (13.4 percent) of those who move from job to job lose
coverage when they change jobs.
Conclusions: While a majority of those who are uninsured
became uninsured as a consequence of a job transition, the
majority of job transitions do not result in a change in health
insurance coverage. Not surprisingly, job loss is more likely to
lead to coverage loss than is job changing.
Implications for Policy, Delivery, or Practice: Despite the
enactment twenty years ago of COBRA, federal legislation to
give those who lose coverage from employment the
opportunity to continue it, a large share of the uninsured are
people who could have continued to enroll in an employmentbased plan but did not.
Primary Funding Source: RWJF
●Health Insurance Consequences of Employment
Transitions
Hanns Kuttner, MA
●Late Payments and SCHIP: Results from a Disenrollee
Survey
Glenn Landers, M.B.A., M.H.A., Patricia Ketsche, Ph.D.,
M.B.A.
Presented By: Hanns Kuttner, MA, Senior Research
Associate, Economic Research Initiative on the Uninsured,
University of Michigan, 555 S Forest Street, Ann Arbor, MI
48104; Tel: (734) 936-1308; Fax: (734) 936-6341; Email:
hkuttner@umich.edu
Research Objective: There is a substantial body of research
explaining the reasons for transitions in and out of
employment and a growing interest in transitions in and out
of insurance coverage. Among those uninsured at a point in
time, loss of employment-sponsored insurance coverage in
one's own name (own ESI) is the most common transition to
being uninsured. This paper ties the loss of own ESI to
several labor market experiences --changing jobs, losing a job,
and experiencing unemployment.
Study Design: Secondary analysis of the 1996 panel of the
Survey of Income and Program Participation (SIPP), a survey
of the non-institutionalized US population. The panel nature
of the SIPP allows us to control for person-specific
characteristics, both those that are observed (e.g., gender) and
unobserved (e.g., attitudes and preferences towards health
insurance.)
Population Studied: Adults (ages 18 to 64) who either
changed jobs or lost a job in the period covered by the panel
(1996 to 2000).
Presented By: Glenn Landers, MBA, MHA, Senior Research
Associate, Georgia Health Policy Center, Georgia State
University, 14 Marietta St., Suite 221, Atlanta, GA 30303; Tel:
404-463-9562; Fax: 404-651-3147; Email: glanders@gsu.edu
Research Objective: Georgia’s S-CHIP Program (PeachCare
for Kids) requires families to pay an income adjusted
premium between $10 and $35 for 1 child and $15 and $70 for
two or more children age six or older. On July 1, 2004, the
Georgia Department of Community Health (DCH)
implemented a three-month waiting period for coverage if the
premium was not received, processed, and posted by the first
of the month prior to the month of coverage. This study
gathered information about the experiences of children during
and immediately after the three-month waiting period.
Study Design: We conducted a bilingual telephone survey of
parents or guardians of PeachCare children affected by this
policy.
Population Studied: Completed surveys were obtained from
1,009 respondents for children who experienced a threemonth waiting period and subsequently re-enrolled and an
additional 647 respondents for children who did not re-enroll
when eligible.
Principal Findings: Among all children who experienced the
three-month waiting period, 89 percent said they had no other
coverage during that time. A large number (48 percent) of
children sought care during their lapse in coverage - most
obtained that care in a doctor’s office, and most paid for the
care at the time of service. About one-quarter of respondents
report that their child was taking a prescription drug prior to
their lapse in coverage. Most (63 percent) of these children
were able to continue their medications during their gap in
coverage. The majority (59 percent) of children who did not reenroll ultimately obtained other coverage, generally through
Medicaid or an employer-sponsored plan. Among
respondents who did not have any current coverage for their
children, over half said they could not afford it.
Conclusions: Almost half of surveyed children needed health
care services during coverage gap. The majority that needed
care did not seek care through an emergency department: half
went directly to a physician’s office. Almost all (88 percent) of
respondents who sought care stated that it was not provided
free of charge, and 57 percent paid for the care themselves.
Thirty-two percent planned to pay for it in the future.
Unfortunately, 19 percent of the respondents who stated their
children needed care did not get it. Approximately nine
months after experiencing a waiting period, 16 percent of
children previously covered by PeachCare had no insurance
coverage, while 84 percent had reenrolled in PeachCare or
obtained alternative coverage.
Implications for Policy, Delivery, or Practice: Further
research might investigate whether or not there was pent up
demand for services for those children who returned to the
program after the waiting period, particularly those who were
not able to obtain care while not covered by PeachCare.
Furthermore, we suggest additional analysis of the link
between utilization of services and the likelihood of
experiencing a lapse in coverage due to non-payment of
premium.
Primary Funding Source: Georgia Department of
Community Health
●Community-based Coverage Options
Glenn Landers, M.B.A., M.H.A., Karen J. Minyard, Ph.D.,
Lindsey Lonergan, M.H.S.
Presented By: Glenn Landers, M.B.A., M.H.A., Senior
Research Associate, Georgia Health Policy Center, Georgia
State University, 14 Marietta St., Suite 221, Atlanta, GA 30303;
Tel: 404-463-9562; Fax: 404-651-3147; Email:
glanders@gsu.edu
Research Objective: With support from the HRSA State
Planning Grant program, the Georgia Governor's Office, with
the Georgia Health Policy Center, sought to assist four
community-based pilot projects in leveraging public-private
partnerships to expand health care coverage among low-wage
workers at small firms in four distinctly different communities
across Georgia. Successful pilots would serve as models for
replication state- and nationwide.
Study Design: Communities were invited to participate based
on the existence of mature community collaboratives that had
a strong history of success implementing programs focused
on health care access. Design support included an insurance
survey of Georgia businesses with over-sampling in the
communities of interest, focus groups with small employers
and low-wage workers of small firms, econometric modeling
of the impact of uninsurance in the pilot communities, and
on-site technical assistance.
Population Studied: Four communities in Georgia: Atlanta
metro - Fulton and DeKalb counties, other metro - the Macon
area, rural north - Dalton, and rural south - Brunswick. The
four distinct profiles (Four Georgias) were revealed in a 2002
survey of 10,000 Georgia households. The four communities
represent approximately 267,000 small firm workers and their
dependents, 160,000 of which are estimated to be uninsured.
Principal Findings: •Employers offering coverage dropped
three percent from 2002, with firms of 25 – 99 employees the
most affected. • The erosion in offer rates was focused on
urban firms – although rural firms were still less likely to offer.
• Between 2002 and 2004, the total average premium cost for
an individual increased 27 percent. • Average monthly wages
increased only for firms that do not offer coverage. • Those
without health insurance spend about 60% per year in health
care costs compared with those with private coverage.
• About 5% of Georgia’s health expenditures are for care of
the uninsured. • Georgians spend about $1,063 annually for
each uninsured Georgian. • Working with key community
leaders who are willing to commit significant time and effort
to the design project was vital to the success of program
development. • Having accurate, detailed data on a variety of
indicators related to the uninsured and local employment, as
well as detailed information on best practices, available at the
outset was critical. • Communities required frequent
interaction with outside facilitators to ensure project work
progresses. • Leveraging local, public financial participation
was the greatest obstacle for the three non-Atlanta
communities. • The state plays a critical role in facilitating the
departmental, regulatory, or legislative change needed to
enact new coverage models.
Conclusions: The creation of community-based public-private
coverage models is technically complicated and largely
dependent on local level leadership with demonstrated
success in community efforts focused on health care access.
Identification of a public share is more challenging in lean
economic times.
Implications for Policy, Delivery, or Practice: State
governments play a critical role in facilitating the
departmental, regulatory, or legislative change needed to
enact community-based coverage models. Due to the unique
circumstances that exist in each community, adaptation rather
than replication may be the order of the day when such
models are considered for duplication.
Primary Funding Source: HRSA
●Health Insurance and the Transition to Financial
Adulthood
Helen Levy, Ph.D.
Presented By: Helen Levy, Ph.D., Research Assistant
Professor, Institute for Social Research, University of
Michigan, 555 S. Forest, Ann Arbor, MI 48104; Tel: 734 615
9587; Fax: ; Email: hlevy@umich.edu
Research Objective: To analyze the high rates of uninsurance
among young adults and the reasons for gaps in coverage
among in this population.
Study Design: A multivariate analysis of determinants of
insurance coverage and how they vary with age. I also
estimate the distribution of remaining uninsured spell length
for individuals by age and the one-year probability of exit from
an uninsured spell by age.
Population Studied: A nationally representative sample of
young adults ages 16 - 30 in the 1996 and 2001 panels of the
Survey of Income and Program Participation.
Principal Findings: The probability of being uninsured peaks
in young adulthood. More than 40 percent of men and 30
percent of women in their early 20s are uninsured. For both
men and women, this peak is driven by a gap of several years
between the rapid drop-off of parental coverage after about
age 17 and a more gradual increase in employer-sponsored
coverage through one’s own or a spouse’s job that does not
begin until several years after parental coverage has declined.
Public coverage also declines sharply for men at age 18 but
only gradually for women, resulting in a higher fraction
uninsured among young men than young women. About half
of the lag in gaining employer-sponsored coverage among
young adults is explained by their relatively tenuous
attachment to the labor force (in particular, part-time or shortterm employment). Compared with older uninsured adults,
young adults who are uninsured experience shorter spells of
uninsurance on average and are more likely to gain insurance
within a year.
Conclusions: Uninsurance among adults is a high-probability
but relatively short-term event that is related to other
predictable dimensions of economic immaturity like job
instability.
Implications for Policy, Delivery, or Practice: Different
public policies are indicated for uninsured young adults than
for older, longer-term uninsured adults. Encouraging young
adults to buy low-cost catastrophic insurance policies in the
individual market would mitigate the consequences of
employment instability for their insurance coverage. Other
policies that target young adults, such as extending Medicaid
coverage through the age of 25, have the potential to reduce
substantially the number of uninsured.
Primary Funding Source: No Funding
●Health, Utilization, and Cost Impacts of Policy Changes
Regarding Post-Cesarean Length of Stay
Jeanne Madden, Ph.D., Dennis Ross-Degnan, ScD, Stephen B.
Soumerai, ScD, Tracy A. Lieu, M.D./M.P.H., Fang Zhang,
Ph.D.
Presented By: Jeanne Madden, Ph.D., Instructor, Dept of
Ambulatory Care and Prevention, Harvard Medical School &
Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th floor,
Brookline, MA 02215; Tel: 617-509-9953;
Email: jeanne_madden@hphc.org
Research Objective: Legislation at the federal level and in
most states mandates that insurers cover 96 hours of postcesarean hospitalization for mothers and newborns. AAP and
ACOG guidelines also recommend 96 hours. Nevertheless,
there are no large-scale studies evaluating the safety of shorter
post-operative stays or the impact of these mandates for
mothers and newborns with cesareans. This research is a
comprehensive examination of a double natural experiment:
an early post-cesarean discharge protocol in an HMO and a
state 96-hour coverage mandate.
Study Design: This retrospective cohort study encompasses
7.5 years of relatively uncomplicated cesarean deliveries
subject to two well-defined policy reversals regarding length of
post-operative stay (“on-off-on”). Study variables based on
claims data and medical records include maternal and
neonatal rehospitalizations and ER visits, office and home
nurse visits, post-discharge maternal complications, feeding
practice and feeding problems, neonatal jaundice diagnoses,
mental health diagnoses and therapies, utilization of antiinfectives, and HMO payments for hospitalization and home
services. We use both pre-post contingency table analyses
with chi-square tests and interrupted time series regression
analyses for all outcomes.
Population Studied: Cesarean deliveries (n=4,559 mothers
and 4,698 neonates) in the population of a large multi-center
staff-model HMO in Massachusetts (the former Harvard
Community Health Plan) between October 1990 and March
1998, excluding dyads with discordant stays or stays >7 nights.
Principal Findings: Post-cesarean stays of 3 nights or less
accompanied 16% of births during 9 baseline quarters and
77% of births during the 11 quarters that followed the new 3night HMO standard protocol. After the later state mandate,
short stays dropped back to 26% of births. Fewer than 1 in 10
dyads received a home visit by a nurse during the baseline
period and the 3-night protocol, but home visits rose to over
44% post-mandate. There was no evidence of impact due to
either the 3-night protocol or the mandate on post-discharge
hospital-based services for mothers or newborns,
breastfeeding rates, or other therapeutic and diagnostic
measures. HMO payments for hospital stays and home visits
declined by about $400 per woman after the shift to a 3-night
protocol, but the later minimum-stay mandate had a
negligible impact on HMO outlays, apparently because of
simultaneous declines in prices within all length-of-stay
groups.
Conclusions: The attempt by this HMO to reduce costs by
discharging women and newborns sooner after cesarean
delivery appears to have been safely implemented. A later
“protective” government mandate conferred no detectable
health benefit in this population, although a secondary
provision in the law resulted in post-cesarean nurse home
visits becoming commonplace for the first time.
Implications for Policy, Delivery, or Practice: Case-by-case
physician discretion, as practiced in this setting, may be key to
ensuring the safety of early post-cesarean discharge.
However, early discharge is clearly a safe option for many
patients, so healthy families who prefer to return home should
be encouraged when follow-up care is accessible. Cost
outcomes of discharge policies in a context of price volatility
may defy expectations.
Primary Funding Source: RWJF, AHRQ, MCHB, and HPHC
Foundation
●Who Disenrolls from Community-Based Health Care
Programs for the Uninsured?
Catherine McLaughlin, Ph.D., Anne Warren, M.P.P., Paula H.
Song, M.H.S.A., M.A.E., Erin Fries Taylor, Ph.D., M.P.P.
Presented By: Catherine McLaughlin, Ph.D., Professor,
Department of Health Management and Policy, University of
Michigan, 555 S. Forest St., Ann Arbor, MI 48104; Tel:
(734)615-9586; Fax: (734)998-6341; Email: cmcl@umich.edu
Research Objective: Community-based health care programs
are gaining popularity as a local solution to address the needs
of the uninsured. Using evidence from three community
programs, this paper investigates who disenrolls from these
programs, how they differed from those who stayed, and
whether disenrollees gain coverage after leaving.
Study Design: We conducted a multi-wave survey of
participants in three Communities in Charge (CIC) programs,
a Robert Wood Johnson Foundation funded initiative aimed at
improving access for low-income, uninsured adults.
Participants were surveyed three times, at enrollment and six
and twelve months after enrollment. The program sites were
Alameda County, California; Austin, Texas; and Southern
Maine. We compare baseline, i.e. time of enrollment,
demographic, employment, and insurance characteristics of
those continuously enrolled in the program to those who
disenrolled during the first twelve months. We assess
disenrollees' insurance status at twelve months to determine
whether they gained insurance and, if so, the type of coverage.
Further, we group respondents based on enrollment status
and health insurance type at twelve months to compare
demographic and employment characteristics and insurance
histories of these groups.
Population Studied: The sample consists of participants in
CIC programs who responded to all survey waves: Alameda
County, n=371; Austin, n=253; and Southern Maine, n=233.
Principal Findings: Disenrollment rates varied significantly by
site, ranging from 11 percent in Alameda County to 62 percent
in Southern Maine. Characteristics of disenrollees also
differed across sites, e.g., disenrollees in Southern Maine and
Austin were significantly younger and more likely to have been
insured than continuous enrollees. Only in Southern Maine
were disenrollees more likely to be employed, although in all
three sites, disenrollees were more likely to work for an
employer who offers coverage. In Alameda County and
Southern Maine, approximately three-quarters of disenrollees
reported disenrolling due to a job that offered health
insurance or eligibility for another program. In Austin,
approximately 40 percent cited these reasons, while another
40 percent reported problems with paperwork. At twelve
months after enrollment, approximately half of disenrollees
were insured, of which half had employer sponsored
insurance (ESI). Approximately 30 percent of disenrollees in
Southern Maine became publicly insured. In Austin and
Southern Maine, disenrollees who gained ESI tended to have
higher incomes, more years of education, and were more likely
to have had ESI coverage in the last year than continuous
enrollees and other disenrollees.
Conclusions: We found evidence that those who stay enrolled
in community-based programs for the uninsured are
predominantly individuals who need access to care for longer
than just short periods. Fewer than half of those who
disenroll are returning to some kind of coverage. The majority
are remaining uninsured, having obtained short term access
to care through the program.
Implications for Policy, Delivery, or Practice: Disenrollment
from community-based programs for the uninsured is not
necessarily problematic. If disenrollment occurs because
participants gain insurance, then these programs enable
participants to access stop-gap care. However, if participants
disenroll but remain uninsured, then programmatic design
should be reevaluated.
Primary Funding Source: RWJF
●The Myth of Emergency Department Diversion and the
Uninsured: Evidence from Three Community-based
Programs
Catherine McLaughlin, Ph.D., Paula H. Song, M.H.S.A.,
M.A.E., Anne W. Warren, M.P.P.
Presented By: Catherine McLaughlin, Ph.D., Professor,
Department of Health Management and Policy, University of
Michigan, 555 S. Forest St., Ann Arbor, MI 48104; Tel: 734-6159586; Fax: 734-998-6341; Email: cmcl@umich.edu
Research Objective: n an effort to control health care costs,
organizations and community programs try to divert
emergency department (ED) use by the uninsured. Rarely
does this approach produce the expected results in part
because the underlying assumptions about utilization,
appropriateness of use, and costs of ED services are not well
understood. This paper provides a closer evaluation of the
myths surrounding ED utilization within the context of
community-based programs for the uninsured. Specifically,
we assess the claim that providing the uninsured with a
medical home will reduce ED utilization and therefore result in
substantial cost savings. We propose that effective ED
diversion of the uninsured hinges on three assumptions: (i)
the uninsured utilize the ED inappropriately, (ii) given a
medical home, patients will use an alternative source of care,
and (iii) costs of ED services are high.
Study Design: We utilize survey data from three sites that
participated in the Communities in Charge (CIC) program, a
grant initiative funded by the Robert Wood Johnson
Foundation that focused on changing the care-seeking
behavior of low income, uninsured adults.
Surveys of program participants were conducted at enrollment
and again at 6 months and 12 months after enrollment in
Alameda County, CA; Austin, TX; and Portland, ME. We
analyze survey data of all participants to compare
demographic characteristics, health status, ED and physician
utilization patterns for the year before enrollment and during
the first year of enrollments for all participants. In addition, we
compare those who changed their ED use to those who did
not change ED use in terms of their overall health care
utilization patterns for the year before enrollment and during
the first year after enrollment.
Population Studied: Program participants from three CIC
programs who participated in all three waves of the CIC survey
(Alameda County, n=303; Austin, n=164; Portland, n=89). All
participants were low-income adults and were ineligible for
public insurance at the time of enrollment.
Principal Findings: Results from our survey analyses find that
in each site, the number of people who used the ED only after
enrollment was approximately the same as the number who
only used the ED beforehand. Thus, the net change in
utilization is negligible. Participants who used the ED both
before and after were more likely to have a chronic condition
or report fair or poor health status. These results suggest that
much of the ED use by these groups of low income, uninsured
adults was appropriate and therefore not likely to be reduced
through ED diversion programs.
Conclusions: Providing a medical home to participants in
community-based programs for the uninsured did not change
net ED utilization. This "steady state" of ED utilization
suggests that participants are utilizing the ED appropriately.
Provided the first two assumptions are not met, the marginal
cost of the minimal number of “diverted” ED visits would
have to be extraordinarily high to result in cost savings.
Implications for Policy, Delivery, or Practice: In order to
achieve cost savings, local communities or programs
attempting to control costs through diverting ED utilization
should evaluate the underlying assumptions necessary to
achieve cost savings.
Primary Funding Source: RWJF
next year was consistently larger, between 7 and 14 percentage
points.
Conclusions: The overall improvement in health insurance
stability from 1984 to 2001 did not come with a narrowing of
gaps between vulnerable populations and the population
overall. The relative rates of coverage remained constant for
most comparisons. The exception was for adults in
chronically poor families. Their coverage rate became
relatively lower over this time period.
Implications for Policy, Delivery, or Practice: Those who
examine health insurance coverage differentials between
vulnerable populations and the population overall should be
aware that in addition to having lower rates of coverage,
vulnerable populations are also more likely to experience loss
of coverage.
Primary Funding Source: RWJF
●Coverage Transition in Vulnerable Populations
Catherine McLaughlin, Ph.D., Matthew Ruttledge
Presented By: James Moser, Ph.D., Senior Health Policy
Economist, , American College of Radiology, 1891 Preston
White Drive, Reston, VA 20191; Tel: 703-648-0690; Fax: 800832-9227; Email: jmoser@acr.org
Research Objective: To compare the use of hospital inpatient
radiology services by the uninsured with those of persons with
health insurance.
Study Design: Statistical analysis primarily of National
Hospital Discharge Survey, a data source that facilitates
identification of both type of service and source of payment.
The uninsured are defined as persons whose principal source
of payment is "self pay" or "no charge."
Population Studied: Hospital inpatients under age 65 who
received one or more radiology services during their episode
of care.
Principal Findings: Uninsured radiology inpatients received
12% fewer services than did their insured counterparts. By
radiology modality, the uninsured tended to receive a larger
proportion of lower-cost modalities (e.g., x-rays) and a smaller
proportion of higher-cost modalities (e.g, computed
tomography).
Conclusions: Uninsured inpatients receive fewer, lower-cost
radiology services compared with insured inpatients. These
differences are due in part to decisions by patients, payers,
hospital management, and attending and/or referring
physicians, but the separate contributions of each to
differences by insurance status are unknown.
Implications for Policy, Delivery, or Practice: If worse health
outcomes for uninsured inpatients can be shown to be
associated with differences in receipt of radiology services,
action may be required on the part of policymakers, payers,
and providers to address these disparities.
Primary Funding Source: No Funding
Presented By: Catherine McLaughlin, Ph.D., Professor,
Health Management and Policy, University of Michigan, 555 S.
Forest, Ann Arbor, MI 48104; Tel: (734) 615-9586; Fax: (734)
998-6341; Email: cmcl@umich.edu
Research Objective: For decades, national surveys recording
health insurance coverage levels have consistently estimated
lower levels of coverage for certain so-called vulnerable
populations. We evaluate changes in those differentials over
the last 20 years, in particular, changes in the rate at which
individuals in these population groups gain and lose health
insurance.
Study Design: We conduct a secondary data analysis of
multiple panels of the Survey of Income and Program
Participation (SIPP). We analyze changes in the probability of
beginning and ending a spell without health insurance in the
first year of each of the eleven SIPP panels begun between
1984 and 2001
Population Studied: Random national sample of noninstitutionalized Americans age 18-64.
Principal Findings: While health insurance status became
more stable between 1984and 2001, the difference in coverage
rates between vulnerable groups and the population overall
has shown little change, with the notable exception of adults
from low income families (annual income <200 percent of
poverty). An analysis of potentially vulnerable subgroups,
including African-Americans, Hispanics, and those in low
income families shows the difference in the probability of
becoming uninsured between the vulnerable group and the
population overall has changed little for African-Americans
and Hispanics, but increased over the past decade for those
who are in chronically poor familes, that is, below 200 percent
of the poverty level all four years of the panel. The gap in the
probability of losing coverage between each of these three
vulnerable populations and the overall population is greater
than the gap in the probability of being without coverage. For
example, while the difference between whites and -AfricanAmericans in insurance coverage was between 7 and 9
percentage points at the outset of each of the eleven waves,
the difference in the probability of losing coverage over the
●Use of Inpatient Radiology Services by the Uninsured
James Moser, Ph.D.
●Use of Prescription Medications and Medical Costs in
Multiple Sclerosis
Katia Noyes, Ph.D., M.P.H., Steven Schwid, M.D., Robert
Holloway, M.D., Ray Dorsey, M.D., Chunyu Li, MS, Huai-Che
Shih, MS
Presented By: Katia Noyes, Ph.D., M.P.H., Assistant
Professor, Department of Community and Preventive
Medicine, University of Rochester School of Medicine, 601
Elmwood Avenue Box 644, Rochester, NY 14642; Tel: (585)
275-8467; Fax: (585) 461-4532;
Email: katia_noyes@urmc.rochester.edu
Research Objective: Multiple sclerosis (MS) affects nearly
400,000 Americans, but data on the medical expenditures in
this population are limited, especially since the introduction of
expensive disease modifying agents (DMAs) in the 1990s.
DMAs (Avonex, Rebif, Betaseron and Copaxone) are highly
expensive biological medications with a potential to slow MS
progression, may have significantly affected costs and
patterns of medical care in MS. Because the age of onset in
MS is around 30 years of age, costs due to lost productivity
are particularly important in MS. This study examines health
services use and expenditures in MS population, with the
focus on indirect, out-of-pocket (OOP), and prescription
medication expenses.
Study Design: We used 1992-2000 Medicare Current
Beneficiary Survey (MCBS), 1996-2003 Medical Expenditure
Panel Survey (MEPS) and Medicare claims data. MS cases
were identified based on participant self-report and diagnostic
codes (ICD-9 CM 340). Using log transformed CPI-adjusted
dollars, multivariate linear models were developed to estimate
total healthcare costs, Medicare-reimbursed total costs, OOP
costs, indirect costs, and total and OOP costs of prescription
medications. Risk adjustment factors included age, gender,
race, residence area, health status (co-morbidities and severity
of MS), and year of services use. Similar negative binomial
models were developed for appropriate utilization. All costs
were adjusted to 2004 U.S. dollars. Analyses incorporated
complex survey design.
Population Studied: 112,871 MCBS person-years representing
Medicare fee-for-service beneficiaries, including 427 from MS
patients. Data from the MEPS included 135,496 person-years,
with 161 from MS patients.
Principal Findings: MS patients had higher costs in all
examined categories. Annual unadjusted total costs were
$9,752 for MS and $2,229 for non-MS in general population,
and $15,866 for MS vs $7,242 for non-MS in the Medicare
beneficiaries. The differences in costs were partially explained
by differences in socio-economic and demographic
characteristics since MS patients were more disabled, less
wealthy, and more likely to be on Medicaid. On average, MS
patients lost more days lost than patients without MS (8 vs 3
days a year). MS patients used significantly more prescription
medications and spent a significantly larger portion of their
income on prescription medications compared to non-MS
patients. MS patients who used DMAs were more likely to
have private insurance coverage, were wealthier and more
likely to be males, and spent more OOP on pharmaceuticals
than MS patients who did not use these agents. Significantly
fewer Medicare patients used DMAs compared to nonMedicare beneficiaries.
Conclusions: Annual direct and indirect medical costs were
much higher for individuals with MS in both the general and
Medicare populations compared to non-MS population. Use
of DMAs was associated with having private health insurance
and higher socio-economic status.
Implications for Policy, Delivery, or Practice: MS places a
substantial financial burden on individuals, private payers,
Medicare, and Medicaid. Factors associated with utilization of
DMAs and potential impact of DMAs on the economic
consequences of MS require more investigation.
Primary Funding Source: NIA, National Multiple Sclerosis
Society (NMSS)
●Did Medicaid/SCHIP Crowd-Out Private Insurance
Coverage among U.S. Low-Income Children?: A Multilevel
Approach
Adetokunbo Oluwole, MS, Dennis Shea, Ph.D.
Presented By: Adetokunbo Oluwole, MS, Graduate Assistant
(Doctoral Student), Health Policy and Administration, The
Pennsylvania State University, 116 Henderson Building,
University Park, PA 16802; Tel: (814) 863-0875; Fax: (814) 8632905; Email: axo129@psu.edu
Research Objective: The objective of this paper is to measure
the extent of crowd-out of private insurance coverage, among
American low-income children, that is attributable to
Medicaid/SCHIP expansion.
Study Design: We combine event history analysis and
multilevel modeling techniques to analyze data from the 1996
panel of the Survey of Income and Program Participation
(SIPP), which covers the period 1996 to 2000. The combined
approach will estimate discrete-time logistic regression
models. Events to be modeled are the following transitions in
insurance coverage: (1) private coverage to Medicaid; (2)
private to uninsured; (3) uninsured to private coverage; (4)
uninsured to Medicaid; (5) Medicaid to private; and (6)
Medicaid to uninsured. In addition to addressing the question
of whether or not children have particular types of health
insurance coverage, event history analysis also incorporates
the timing of such coverage and transitions. Multilevel
modeling accounts for cross-state variations in coverage
transition rates as well as corrects for within-group correlation
and non-constant error terms. State-level data from other
sources such as the Area Resource Files, Regional Economic
Information Services, and the Centers for Medicare and
Medicaid Services will be appended to the SIPP dataset. To
address the issue of heterogeneity among states, the models
estimated in this study control for state- and program-specific
factors, which many previous studies failed to account for.
Population Studied: The paper focuses on children living in
low-income families in the United States. The sample for the
study consists of unmarried children nineteen or younger, and
living in families with incomes at or below 300 percent of the
federal poverty level (FPL). The analytic sample is expected to
comprise about 8,000 low-income children.
Principal Findings: Preliminary analyses show that the
conditional probability of transition from private insurance to
Medicaid/SCHIP started to increase shortly after states began
to implement their Medicaid/SCHIP expansion programs.
Conclusions: Given the controversial estimates of crowd-out
in previous studies, this study’s use of combined techniques
of event history and multilevel modeling will provide more
accurate and updated estimates using the 1996 panel of the
SIPP dataset, which no other study has analyzed.
Implications for Policy, Delivery, or Practice: The
implementation of the Medicaid/SCHIP, which began shortly
after the major welfare reform of 1996, represented a more
recent effort to expand health insurance among lower income
populations in the U.S. Previous studies have shown that
earlier Medicaid expansions significantly increased public
program participation and have reduced the number of
uninsured individuals. However, empirical evidence indicates
that the reduction in the number of uninsured has been offset
by declines in private insurance coverage. Because the
Medicaid/SCHIP expansions targeted a different population
than earlier expansions and took a different form, a detailed
study of these more recent efforts is needed. Results from this
study will provide more insight on how best health insurance
coverage policies can be directed to have maximum positive
effect on the targeted (uninsured) population.
Primary Funding Source: Graduate Assistantship
●A Card and A Home: Types of Insurance Coverage and
Usual Sources of Care
Stephen Petterson, Ph.D.
Presented By: Stephen Petterson, Ph.D., Senior Health Policy
Researcher, Robert Graham Center, American Academy of
Family Physicians, 1350 Connecticut Avenue, N.W., Suite 201,
Washington, DC 20036; Tel: (202)331-3360; Fax: (202)3313374; Email: SPetterson@AAFP.org
Research Objective: The main objective is a thorough
analysis of the relationship between type of health insurance
coverage and usual source of care. Prior studies have
conclusively shown that the uninsured and underinsured are
substantially less likely to have a usual source of care. Little is
known about the extent to which the likelihood of having a
usual source of care varies between public and private
insurance coverage as well as between traditional fee-forservice and managed care insurance. Likewise, little is known
about the relevance of insurance types on the character of a
person’s usual sources of care, including the specialty of the
usual provider of care and whether relies on a facility rather
than a particular provider.
Study Design: This study is based on secondary data using a
quasi-experimental design. We use data from the 2002
Medical Expenditure Panel Survey (MEPS). The association
between insurance type and usual source of care type is
examined in models that control for demographic
characteristics as well as measures of physical and mental
well-being.
Population Studied: The MEPS sample is representative of
the civilian non-institutionalized population. In our study,
separate analyses are carried out for children, non-elderly
adults and the elderly.
Principal Findings: Adjusting for age and health, Medicare
recipients are by far the most likely to have a usual source of
care. Among insured non-elderly adults, those covered by
private or Medicaid fee-for-service insurance are the least likely
to have a usual source of care. Moreover, the nonelderly in
private HMOs are significantly more likely to have a usual
source of care than their counterparts in Medicaid HMOs.
Children covered by private insurance are more likely to have a
usual source of care than children covered by public
insurance. The nonelderly with private insurance are
significantly less likely than their counterparts with public
insurance to rely on a facility than a particular provider.
Finally, among those who can name a particular provider as
their usual source of care, persons in HMOs and in other
managed care plans are more likely to have a family physician
or general practice physician than a provider from another
specialty.
Conclusions: Type of insurance of insurance coverage is
strongly associated with type of usual source of care for both
children and adults. With important exceptions, persons
covered by HMO and managed care plans are more likely to
have a usual source of care and more likely to have a family
physician. Medicaid recipients often do not have a usual
source of care and, among those that do, they are the most
likely to rely on a facility rather than a particular provider.
Implications for Policy, Delivery, or Practice:
Previous work has shown that insurance coverage and having
a usual source of care are important and independent
predictors of access to necessary medical care. Our findings
suggest that policies designed improve health outcomes
should address the implications of potential changes for the
combined impact of health insurance coverage and providing
all individuals with a medical home.
Primary Funding Source: Other
●Emergency Department Visits: Is This the Right Place?
Mary Price, MA, Richard Brand, Ph.D., Joseph Newhouse,
Ph.D., Joseph Selby, M.D., M.P.H., John Hsu, M.D., MBA,
MSCE
Presented By: Mary Price, MA, Sr. Consulting Data Analyst,
Division of Research, Kaiser Permanente Northern California,
442 Brimhall St., St. Paul, MN 55105; Email:
Maggie.Price@kp.org
Research Objective: Previous studies suggest that patients
often seek care from the emergency department (ED)
unnecessarily, resulting in overcrowding and inefficient
resource use. We investigated the severity of ED visit
diagnoses, and the association between visit severity and
subsequent hospitalization or deaths.
Study Design: For all ED visits (1999–2001) in a large prepaid
integrated delivery system (IDS), we used the New York
University ED Diagnosis Algorithm to classify visits as low or
high-severity. This algorithm assigns probabilities to four
ordered categories for each visit’s ICD-9 diagnosis; the sum of
the four probabilities equals 100%. We classified visits as lowseverity when there was a >=75% probability that the visit
diagnosis either did not require emergency care or could have
been treated in a primary-care setting. We classified the visit
as high-severity when there was a >=75% probability that the
visit diagnosis did require preventable or unpreventable
emergency care. We used the most severe diagnosis when
there were >1 visit diagnosis; visits were indeterminate if the
probability was <75%. Using GEE models, we examined the
patient and system factors associated with low-severity ED
diagnoses, stratified by insurance type (commercial or
Medicare). We also examined the association between visit
severity and subsequent hospitalization or death, adjusting for
year, month, age, gender, neighborhood socio-economic
status, comorbidity, prior utilization, having a regular
physician, cost-sharing, and medical center. We repeated the
analysis using proportional hazard models and 50% and 90%
probability thresholds.
Population Studied: All 628,272 subjects were IDS members
in January 1999 with ?1 ED visit in 1999-2001.
Principal Findings: There were 1,085,229 ED visits (19992001): 29% low and 20% high-severity visits, with 52%
indeterminate visits. Of the low-severity visits, 4% resulted in
a subsequent non-elective hospitalization within one-day and
0.7% resulted in death within 30 days. In addition to several
patient characteristics, factors associated with low-severity
visits included not having a regular physician and low ED
copayments in both insurance groups, and high drug
copayments in the commercial group. Compared with highseverity visits, low-severity visits were less likely to result in a
subsequent non-elective hospitalization (OR=0.14, 95%CI:
0.13—0.14) or in death within 30 days (OR=0.21, 95%CI:
0.19—0.23) for subjects with commercial insurance; the
results for hospitalizations (OR=0.21, 95%CI: 0.20—0.21) and
deaths (OR=0.30, 95%CI: 0.28—0.31) were similar for
Medicare subjects. The findings were robust across analytic
approaches.
Conclusions: Almost one third of ED visits were for lowseverity conditions, which are substantially less likely to result
in subsequent hospitalizations or death. Several system
factors, such as having a regular physician and higher ED
copayments, are associated with decreased use of the ED for
low-severity conditions.
Implications for Policy, Delivery, or Practice: Use of the ED
for low-severity conditions is potentially inefficient. These data
suggest that even in an insured population within an
integrated system, many patients use the ED for low-severity
conditions. More research is needed to examine the factors
that encourage patients to make more efficient choices about
where to seek care and the clinical and economic
ramifications.
Primary Funding Source: AHRQ, The Commonwealth Fund
●Safety Net on the Edge: Growing Pressures on Health
Centers' Ability to Meet Demand
Michelle Proser, M.P.P., Daniel R. Hawkins
Presented By: Michelle Proser, M.P.P., Director of Policy
Research, National Association of Community Health Centers,
1400 Eye Street, NW, Suite 330, Washington, DC 20005; Tel:
(202) 296-1960; Fax: (202) 296-3526;
Email: mproser@nachc.com
Research Objective: To determine national trends in
community health center patient characteristics and the
affects of such trends on the financial stability of health
centers nationwide.
Study Design: Analyzed health center patient and financial
data from the Uniform Data System (UDS) for calendar years
1999-2004. All federally-funded health centers must report
UDS annually to the federal Bureau of Primary Health Care. In
2004, 914 health center organizations from across the country
reported UDS. UDS data were compared to US Census and
other national data sources where possible in order to
contrast health center and US trends.
Population Studied: Analyzed data on all patients visiting
federally-funded health center organizations during study
years (13.1 million patients in 2004 UDS). Patients tend to be
low-income, and be uninsured or publicly insured. Also
analyzed health center costs of care, third-party charges and
collections, and other revenue reported in UDS.
Principal Findings: Between 1999 and 2004, the number of
patients treated by health centers increased by 46%. Between
1999 and 2003, the number of low-income patients who
sought care at health centers grew four times as fast as the
number of low-income Americans. Over the same time
period, the number of uninsured patients grew nearly three
times as fast as the number of uninsured nationally. Medicaid
continues to be the dominant insurer of health center
patients, covering 36% of patients in 2004. Federal health
center grant revenue per patient has not kept up with cost per
patient ($272 vs. $504 in 2004). Concurrently, payments from
Medicare, other public insurance, and private insurance are on
the decline. While Medicaid is the most reliable payer, paying
an average of 87% of health centers’ costs, private insurance
is the worst payer, covering only 57% of costs. Although
average operating margins hover around 1% annually for the
study period, those health centers with negative or zero
margins on average collect less from Medicaid, Medicare, and
other public insurance programs compared to health centers
with positive operating margins.
Conclusions: The demand for health center services is on the
rise, especially among low-income and uninsured populations
that may be costlier to treat. Simultaneously, health centers
are experiencing rising costs of care also seen across the
health care system, and they continue to rely on a diverse mix
of revenue sources to deliver their current scope of services.
Although Medicaid is currently the most reliable payer,
program cuts endanger health centers’ ability to meet their
patients’ needs.
Implications for Policy, Delivery, or Practice: Given rising
numbers of uninsured and those in poverty, health centers
likely will continue to experience growing demand for their
services. As the largest insurer of health center patients,
adequate Medicaid payments and sustained Medicaid
enrollment are essential to a health center’s financial viability.
Diminishing revenues from other sources exacerbate the
financial pressures on health centers. While health centers on
average have slim positive operating margins, one unexpected
emergency or change in payment policy could jeopardize their
financial stability, threatening the existence of primary care for
an entire community.
Primary Funding Source: No Funding
●Insurance Instability Among a National Sample of
Children in the Child Welfare System
Ramesh Raghavan, M.D., Ph.D., Gregory A. Aarons, Ph.D.,
Laurel K. Leslie, M.D., M.P.H.
Presented By: Ramesh Raghavan, M.D., Ph.D., Policy
Director, The National Center for Child Traumatic Stress,
University of California, Los Angeles, 11150 W Olympic Blvd
Suite 650, Los Angeles, CA 90064; Tel: (310) 235-2633 x233;
Fax: (310) 235-2612; Email: rraghavan@mednet.ucla.edu
Research Objective: To estimate the prevalence, patterns,
and predictors of health insurance instability among a national
sample of children in the child welfare system.
Study Design: We analyzed child-level data from four waves
of the National Survey of Child and Adolescent Well-Being
(NSCAW), the first nationally representative study of children
coming into contact with child welfare agencies. Outcomes
were types of current insurance status – Medicaid, private,
federal, or uninsured – at each wave. Predictors included
child-level sociodemographic characteristics, maltreatment
history, placement status, Child Behavior Check List (CBCL)
scores, caregiver education, and log of caseworker experience
in months. We performed weighted descriptive and bivariate
analyses of insurance change over time within types of
insurance categories, and conducted survey-weighted logistic
regressions to estimate odds of being uninsured, adjusting for
child-, caregiver-, and caseworker-level characteristics.
Population Studied: 3041 children aged between 2 and 16
years investigated by child welfare agencies for suspected
child maltreatment. Data was used from Wave 1 (November
1999 to April 2002), and 12-, 18-, and 36-month follow up
waves (Waves 2 through 4).
Principal Findings: Overall, 52% of children and adolescents
were stably insured across all 4 waves, and less than 1% were
never insured. Proportions of children enrolled in Medicaid
increased across waves (from 62% at Wave 1 to 69% at Wave
4), proportions of those uninsured declined (from 12% to 7%
over the same time period), and proportions of those in
private or federal insurance plans were stable at around 25%.
Acquisition of insurance coverage by the previously uninsured
occurred steadily across waves, with 5.2% becoming insured
between Waves 1 and 2, 4% between Waves 2 and 3, and 4.5%
between Waves 3 and 4. However, losses in insurance
coverage also occurred over time, with 4.5% losing coverage
between Waves 1 and 2, 2.4% between Waves 2 and 3, and
3.4% between Waves 3 and 4. On logistic regression older
age, African-American or Latino ethnicity, having caregivers
with a high school or less education, and having less
experienced caseworkers were all associated with higher odds
of being uninsured at each wave. Children and adolescents
who were placed in homes other than their own displayed a
greater degree of insurance stability than children maintained
within their own homes.
Conclusions: Children within the child welfare system exhibit
a lesser degree of churning when compared to Medicaid- or
SCHIP-enrolled children in the general population. Such
instability occurs immediately following entry into the child
welfare system. Children in foster care placement (which
usually makes such children Medicaid-eligible) are more stably
insured than those maintained in-home.
Implications for Policy, Delivery, or Practice: Expansion of
categorical Medicaid eligibility benefits to children in the child
welfare system maintained within their own homes is likely to
be successful at preventing insurance instability. Child welfare
agencies should consider health needs in addition to
assessing risk while making placement decisions. Caseworkers
should pay particular attention to the health needs of children
maintained in-home, and work with caregivers to secure
insurance coverage for these children.
Primary Funding Source: No Funding
●Use of Preventive Care by the Working Poor
Joseph S. Ross, M.D., Susannah M. Bernheim, M.D., Elizabeth
H. Bradley, Ph.D., William T. Gallo, Ph.D.
Presented By: Joseph S. Ross, M.D., Robert Wood Johnson
Clinical Scholar, Internal Medicine, Yale University, Room IE61 SHM, P.O. Box 208088, New Haven, CT 06520-8088; Tel:
(203) 785-5920; Fax: (203) 785-3461; Email:
joseph.s.ross@yale.edu
Research Objective: Although lower-income adults are less
likely to receive preventive care when compared with higherincome adults, it is not clear whether working adults living in
poverty — the working poor — are similarly at risk. Our
objective was to examine the association between poverty and
use of preventive care among older working adults.
Study Design: We performed a cross-sectional analysis of
data from the 1996, 1998 and 2000 waves of the Health and
Retirement Study (HRS), a nationally-representative sample of
U.S. adults aged 51-61 in 1992. We studied five main outcome
measures: self-reported use of (1) Pap smears for cervical
cancer screening, (2) mammograms for breast cancer
screening, (3) serum prostate-specific antigen measurement
for prostate cancer screening, (4) serum cholesterol screening
for cardiovascular risk reduction, and (5) influenza
vaccination. Adults whose annual household income was
within 200% of the household-size adjusted federal poverty
level were defined as living in poverty. We used 2 stages of
multivariable analysis to examine the association between
working poverty and each outcome, with all analyses taking
into account the complex survey design and weighted
sampling probabilities of the data set. The first stage analysis
adjusted for socio-demographic covariates including age,
gender, race/ethnicity, marital status, household size, and net
worth, as well as self-reported health status, insurance status,
and annual physician visits. In order to understand how
education may moderate the effect of working poverty, we
performed a second-stage analysis that additionally adjusted
for education.
Population Studied: 6,835 community-dwelling working
adults participated in at least one wave of the HRS from 1996
through 2000. Repeated assessment yielded a total of 10,088
observations of working adults: 1,196 (12%) living in poverty
and 8,896 (88%) not living in poverty.
Principal Findings: Among eligible adults, use of preventive
services ranged from 30% for serum cholesterol screening to
76% for breast cancer screening. First-stage multivariable
analysis demonstrated that working adults living in poverty
were significantly less likely to receive each preventive service
when compared with working adults not living in poverty (Pvalues < 0.05). Second-stage multivariable analysis
demonstrated that working adults living in poverty were
significantly less likely to receive breast cancer screening (OR
0.70, 95% CI, 0.58-0.85, P<0.001), prostate cancer screening
(OR 0.72, 95% CI, 0.58-0.91, P=0.005), and cholesterol
screening (OR 0.74, 95% CI, 0.64-0.86, P<0.001), while
education moderated the effect of working poverty on use of
cervical cancer screening (OR 0.85, 95% CI, 0.70-1.03, P=0.10)
and influenza vaccination (OR 0.88, 95% CI, 0.75-1.03,
P=0.11).
Conclusions: While use of preventive care varied markedly by
service and was below recommended targets for every service
except breast cancer screening, the working poor were less
likely to receive important preventive care services.
Implications for Policy, Delivery, or Practice: Difficult
choices between purchasing daily necessities and preventive
care leave the working poor at risk for preventable deaths and
avoidable health care costs. Reducing economic and noneconomic barriers to preventive care, by easing access to
safety-net providers, providing means-tested preventive care
vouchers, or expanding Medicare eligibility, could yield
significant health benefits. In addition, the role of education
as a moderator suggests that health literacy may influence use
of preventive care.
Primary Funding Source: No Funding
●Arkansas and Massachusetts: a Comparison of Health
Insurance Status in Two States
Joseph Thompson, M.D., M.P.H., Kevin W. Ryan, JD, MA,
Jennifer L. Shaw, M.P.H., MAP, Kirk K. Larsen, MA, Patricia M.
Gallagher, Ph.D., Anthony Roman, MA
Presented By: Joseph Thompson, M.D., M.P.H., Director,
Arkansas Center for Health Improvement, 1401 West Capitol,
Suite 300, Little Rock, AR 72201; Tel: (501) 526-2244; Fax: (501)
526-2252; Email: thompsonjosephw@uams.edu
Research Objective: The increasing number of uninsured has
created significant challenges for public and private
stakeholders in states across the nation. Operating within
balanced budget mandates, and with no federal solution on
the horizon, states have had various responses and
reallocated resources to optimize financial coverage and meet
the basic health needs of their citizens. Given current budget
constraints and increased healthcare utilization, the ability of
states to continue to adequately address healthcare needs is
in question.
Study Design: We undertook this study of two states
(Arkansas and Massachusetts) in order to generate state level
economic and healthcare system profiles. Information was
obtained from multiple data sources in order to create these
state profiles. Sources included US Census Bureau, the
Agency for Healthcare Research and Quality Medical
Expenditure Panel Survey, state Departments of Health and
Human Services, and state-specific household surveys
conducted in 2004. Importantly, the same household survey
instrument, which collected detail information about health
insurance and healthcare system utilization in each state, was
fielded in both states by the University of Massachusetts
Center for Survey Research using random digit dialing
methodology.
Population Studied: The population studied consisted of
Arkansas and Massachusetts household members.
Respondents numbered 6,684 and 12,749 in Arkansas and
Massachusetts respectively. A weighting system was applied
to estimate the number of people in households for both
states.
Principal Findings: Analyses of national datasets and results
from the household surveys yielded substantively disparate
profiles of the states under review. Estimates indicate that
17.2% of all Arkansans were uninsured in 2004, while only
7.4% of all Massachusetts residents were without coverage
that year. More than twice as many Arkansas adults aged 1964 were uninsured (24.4%) as their counterparts in
Massachusetts (10.6%). Similarly, over three times as many
Arkansas children aged 0-18 were uninsured (10.4%) as
Massachusetts children (3.2%). The 2004 median household
income in Arkansas was estimated at $32,983 and $55,658 in
Massachusetts. Additionally, in 2003 only 42.2% of Arkansas
private sector firms offered health insurance to their
employees while approximately 66% of private firms in
Massachusetts offered health insurance that same year.
Comparison of public sector eligibility reveals greater
programmatic eligibility for adults aged 19-64 years in
Massachusetts than in Arkansas (e.g. disabled adult income
eligibility threshold of 133% to receive Medicaid benefits as
contrasted with 72% in Arkansas and existence of premium
assistance purchasing programs for working and non-working
Massachusetts adults that do not exist in Arkansas).
Conclusions: The ability for low-income states to insure the
19-64 year old adult population is limited. In each of these
states, neither private nor public sectors have adequate
resources to achieve high and consistent levels of insurance
coverage across all ages. This comparison of Arkansas and
Massachusetts demonstrates that increased household
income, private sector offering and public sector program
availability are insufficient in and of themselves to reduce
uninsurance rates to acceptable levels.
Implications for Policy, Delivery, or Practice: The federal
Medicaid matching assistance program, based upon average
per capita income alone, may not sufficiently level the playing
field for all states.
Primary Funding Source: HRSA, RWJF
●Dual Use of Medicare and the Veterans Health
Administration: Are There Adverse Health Outcomes?
Fredric Wolinsky, Ph.D., Thomas Miller, MBA, Hyonggin An,
Ph.D., Paul Brezinski, MBA, Tomas Vaughn, Ph.D., Gary
Rosenthal, M.D.
Presented By: Fredric Wolinsky, Ph.D., John W. Colloton
Chair, Health Management and Policy, The University of Iowa,
200 Hawkins Drive, E-205GH, Iowa City, IA 52242; Tel: 319384-5129; Fax: 319-384-5125;
Email: fredric-wolinsky@uiowa.edu
Research Objective: Millions of veterans are eligible to use
the Veterans Health Administration (VHA) and Medicare
because of their military service and age. This paper examines
whether an indirect measure of such dual use increases the
risk of mortality.
Study Design: Data from the Survey of Assets and Health
Dynamics among the Oldest Old (AHEAD) were linked to
Medicare claims and the National Death Index. Dual use was
indicated when the self-reported number of hospital episodes
in the 12 months prior to baseline was greater than that
observed in the Medicare claims. The independent effect of
dual use on mortality was estimated using proportional
hazards regression.
Population Studied: Nationally representative sample of
1,566 self-responding men who were 70 years old or older at
the time of their baseline interviews in 1993.
Principal Findings: 97 (11%) of the veterans were classified
as dual users. 817 (52%) men had died by December 31,
2002, including 67% of the dual users and 51% of all others (p
< .001). Adjusting for demographics, socioeconomics,
comorbidity, hospitalization status, and selection bias at
baseline, as well as subsequent hospitalization for ambulatory
care sensitive conditions, the independent effect of dual use
was a 61.8% increased risk of mortality (AHR =1.618; p = .02).
Conclusions: An indirect measure of dual use of VHA and
Medicare services in veterans was associated with an
increased risk of death.
Implications for Policy, Delivery, or Practice: Dual use is
significantly associated with increased mortality, and the likely
etiological mechanism involves poor coordination between
the VHA and Medicare health care systems. Although the
focus of this paper was on dual use of the VHA and Medicare
at the system level, the real problem is the increasingly
fragmented and uncoordinated nature of health care at all
levels of delivery. Therefore, improvement of communication
tools that facilitate better patient care management under a
single primary care practitioner is warranted.
Primary Funding Source: NIA
●The Rural Safety-net: Collaborations between Rural
Community Health Centers and Critical Access Hospitals
Sudha Xirasagar, MBBS, Ph.D., Michael Samuels, DrPH
Presented By: Sudha Xirasagar, MBBS, Ph.D., Research
Assistant Professor, Health Services Policy and Management,
University of South Carolina, Arnold School of Public Health,
800 Sumter St., Columbia, SC 29208; Tel: (803) 576-6093; Fax:
(803) 777-1836; Email: sxirasagar@sc.edu
Research Objective: Because rural areas have limited
healthcare resources, existing institutions need to coordinate
and complement one another’s services to maximize their
impact. This study sought to: 1. Identify model collaborations
between between rural Community Health Centers (CHC) and
critical access hospitals (CAH), and the barriers and
facilitators for collaboration. 2. Assess the prevalence and
functionality of collaborative relationships at a national level
Study Design: Qualitative study of five model collaborations
through site visits (in 2003), followed by national survey of
eligible CAHs (in 2004) to assess the prevalence and
functionality of collaborations, as well as directions for policies
concerning improving rural health safety networks.
Population Studied: Phase 1: Site visits of five model CHCCAH collaborations identified by directors of state primary
care associations, state offices of rural health, and state
hospital associations. Phase 2: Survey of CEOs of all 386
CAHs in the US with a CHC within a 60-mile radius (n=161,
response rate 41.6%).
Principal Findings: Qualitative: 1. Movement towards an
integrated delivery system model 2. Service consolidation:
Mutual cross-referral, sharing physicians, shared laboratory
and radiology services and MIS improved the continuum of
care, prevented duplication of services, and saved costs 3.
Shared HR practices including recruiting, credentialing, joint
training, and medical malpractice insurance for mutual benefit
4. Mutual leveraging of strengths for jointly realizing benefits
of HRSA’s 340-B pharmacy program. 5. Lack of competition
favors collaboration 6. Major barriers to collaboration:
Competition, Lack of trust, Different corporate cultures,
Preoccupation with routine responsibilities, Conflicting
regulations. 7. Major facilitators: Vision about safety-net role;
Funded, separate entity to establish the collaboration; Agree to
compete on certain aspects while collaborating on others;
Shared patient information system facilitates long term
collaboration. National survey findings: CAH responses to
survey: 161/386 (41.7%) Report collaborations: 24 (14.9% of
respondents, or 6.2% of total CAHs with a CHC within 60
miles) Service areas: 15 radiology, 13 specialty care, 12
laboratory, 9 primary care, 7 pharmacy, 6 wellness programs
Satisfaction with collaboration: - Clinical: Primary Care 100%
Wellness Programs 50% - Human Resources: Training
90.9%` Shared Staff 72.7% - Administrative: Malpractice
Insurance 80% Quality assurance 80% Reasons for lack of
collaboration (n=137 CAHs without collaboration): - Unaware
of CHC in vicinity – 20.4% - No proposal from CHC – 40.9%
- Not considered it – 37.2% - Other priorities – 39.4%
Barriers to collaboration (n=24 with collaboration):
- Competition – 58.3% - Different corporate cultures – 50%
- Lack of trust – 45.8% Facilitators for collaboration: Seed
money – 48.9% Funded unit – 38.7% Funded facilitator –
36.5%
Conclusions: Lack of awareness/information is a key reason
for lack of CAH-CHC collaborations, despite HRSA’s FLEX
program emphasis on rural networks. Lack of funding
mechanisms to establish the collaboration is the next major
reason
Implications for Policy, Delivery, or Practice: Policy
recommendations - National/state level conferences and
meetings between CHCs and CAHs - Expert-driven workshops
(national and state level) drawing on expertise from model
partnerships - Funding mechanisms to facilitate collaborative
relationships
Future research - Cost-benefit and effectiveness studies of
functional areas of collaboration - Comparative study of
“corporate culture” differences between rural CHCs and CAHs
- Evaluate barriers in CHC and CAH legislation and program
regulations.
Primary Funding Source: National Rural Health Association
●The Great Divide in Access to Health Care in Suburban
and Inner City Communities: Assessment of
Hospitalizations for Ambulatory Care Sensitive Conditions
Gary Young, MA, Jo Anne Romano
Presented By: Gary Young, MA, Executive Vice President,
Strategic Planning and Government Relations, Cooper
University Hospital/Robert Wood Johnson Medical SchoolCamden, One Cooper Plaza, Camden, NJ 08103; Tel: 856-3423002; Fax: 856-342-3299; Email: Younggary@cooperhealth.edu
Research Objective: To assess the level of access to primary
health care services and the impact of the health care delivery
system at work in inner city and suburban environments by an
empirical study of age- and sex-adjusted rates of
hospitalization for ambulatory care sensitive conditions.
Study Design: A post-hoc, population-based study focused on
a comparative analysis of UB-92 hospital abstract data (20002003) for Camden, New Jersey—the second poorest city in the
United States—with the southern New Jersey region focusing
on age and sex-adjusted rates of hospitalizations for 19
ambulatory care sensitive conditions (preventable, rapid
onset, and chronic conditions). The study replicates the
methodology for studying ambulatory care sensitive
conditions employed in McClellan, M.D., et al., Refinement of
the Healthcare Cost and Utilization Project (HCUP) Quality
Indicators- AHRQ, 2001. Rates of hospitalization are
presented for age/sex cohorts and odds-ratios are utilized to
present statistically meaningful variations in rates of
hospitalization for Camden City residents as compared with
the suburban southern New Jersey region.
Population Studied: Hospitalization abstract data for
residents of the City of Camden (pop. 75,000) and the seven
counties of southern New Jersey (1.72 million).
Principal Findings: 17% of the hospitalizations for the City of
Camden were found to be for preventable, ambulatory care
sensitive conditions. The payer mix of these hospitalizations
were predominately Medicaid, Managed Medicaid and charity
care, while the cost of this care was estimated to be $25MM.
Hospitalizations for ambulatory care sensitive conditions
ranged from 20% to 360% higher in the City of Camden than
in the suburban New Jersey region, with the highest rates
associated with diabetes, asthma, hypertension.
Other findings presented detail specific conditions and the
population cohorts most at risk in the different communities.
Conclusions: Data suggests that there is a fundamental
breakdown in the health care delivery system in the City of
Camden with clear evidence of a lack access to quality primary
care and management of chronic conditions and primary care
follow-up.
Implications for Policy, Delivery, or Practice: A number of
implications for policy are developed in the paper including
the following: Medicaid, managed Medicaid, and New Jersey’s
system of charity care reimbursement needs to be
restructured to incentivize physicians to provide greater
access to primary care and disciplined follow-up of chronic
health conditions. Hospitals need to leverage their resources
to create alternative health care delivery mechanisms focused
on increased access to primary care and disease
management.
Primary Funding Source: No Funding
●Access to Eye Care in the United States, 2002
Xinzhi Zhang, M.D., Ph.D., Sanjat Kanjilal, M.P.H., Michael R.
Duenas, OD, K.M. Venkat Narayan, M.D., Jinan B. Saaddine,
M.D., M.P.H.
Presented By: Xinzhi Zhang, M.D., Ph.D., Senior Service
Fellow, , Centers for Disease Control and Prevention, 4770
Buford Hwy, N.E. (K10), Atlanta, GA 30341; Tel: 770-488-4877;
Fax: 770-488-1148; Email: xbz3@cdc.gov
Research Objective: Approximately 1 in 28 Americans older
than 40 years have visual impairment and many more have
asymptomatic eye diseases that need eye care services. Access
to eye and vision care services has become a major public
health concern. We aim to estimate the level of access to eye
care, and explore barriers to eye care in the nation.
Study Design: We used the 2002 National Health Interview
Survey (NHIS), an annual cross-sectional population-based
survey of households across the United States. We analyzed
data from 30,920 adults aged 18 and older using a modified
well-established behavioral access model. We evaluated
indicators of both potential access and realized access and
their relationship. Indicators of potential access to eye care
included age, sex, marital status, race/ethnicity, education,
income, health insurance, region, diabetes, and vision
problems. Indicators of realized access to eye care included
visiting eye doctor in the past 12 months, having a dilated eye
exam in the past 12 months, and the inability to afford
eyeglasses when needed. We used Multivariate logistic
regressions for the three dichotomous realized access
variables to estimate odds ratios (OR), conditional margins
(CM), and predictive margins (PM). All analyses were
weighted to adjust for the complex sample design and to
make estimates representative of the U.S. civilian noninstitutionalized population.
Population Studied: U. S. Population
Principal Findings: On average, 60% (95%CI: 58%-61%) of
people with vision problems visited eye doctor in the past 12
months and 59 % (95%CI: 57%-60%) had dilated eye exam in
the past 12 months, compared to 32% (95%CI: 31%-33%) and
34% (95%CI: 33%-35%) of people without vision problems
respectively. Additionally, 11.1% (95%CI: 10.1%-12.0%) of
people with vision problems cannot afford eye glasses
compared to 4.3% (95%CI: 4.0%-4.6%) of people without
vision problems. Controlling for all other potential access
variables in the model, the probability of visiting eye doctor in
the past 12 months and the probability of having a dilated eye
exam in the past 12 months increased with age, education,
and income (P <0.01). Moreover, having health insurance,
being female, having diabetes, or having vision problems
increased the probability to use eye care services for each (P
<0.01). Inability to afford eye glasses was significantly
associated with being unmarried, being female, having low
income, without insurance, having diabetes, or having vision
problems (P <0.01).
Conclusions: There is inequity of access to eye care in the
United States. These findings will help target limited
resources, identify new interventions, and set a baseline in the
effort to eliminate disparities in access to eye and vision care.
Implications for Policy, Delivery, or Practice: Conditions
causing vision impairment and blindness are often
asymptomatic in the early and treatable stages. Populationbased survey is an effective way to systematically monitor and
evaluate access to eye care. Public health policy needs to be
developed to increase access to eye care, allocate scarce
recourses, and achieve a population with healthy vision in the
U.S.
Primary Funding Source: No Funding
●Uninsured Families
Erika Ziller, MS, Andrew F. Coburn, Ph.D., Nath Anderson,
M.P.H.
Presented By: Erika Ziller, MS, Research Associate, Muskie
School of Public Service, University of Southern Maine, PO
Box 9300, Portland, ME 04104-9300; Tel: (207) 780-4615;
Email: eziller@usm.maine.edu
Research Objective: Although numerous studies have
examined the prevalence and characteristics of the U.S.
uninsured, research into the coverage of entire families has
been limited. The purpose of this study was to examine health
insurance coverage at the family level, to determine the extent
to which U.S. households are fully covered by health
insurance, fully uninsured, or have a mix of insured and
uninsured members. Among partially uninsured families, we
also identified the source(s) of coverage for insured members,
including Medicare, Medicaid/SCHIP, private insurance, and a
public/private mix. With these analyses we offer critical new
information about the extent of uninsurance within U.S.
families.
Study Design: Employing a combination of bivariate and
multivariate techniques, we use a pooled sample of the 2001
and 2002 Medical Expenditure Panel Survey (MEPS) to
estimate family health insurance coverage rates, and to
identify the characteristics associated with different family
coverage mixes. To address known sampling errors in the
MEPS, we apply family-level weights and use statistical
techniques to adjust for data clustering. Using multinomial
logit (MNL) modeling, we estimate the likelihood of being
fully or partially uninsured, compared to fully insured, based
on family characteristics. Among partially uninsured families,
our MNL models measure the relationship between
sociodemographic and employment characteristics and
source(s) of coverage among insured family members, with
fully uninsured families as the referent.
Population Studied: We examined the family insurance
coverage status of a nationally representative sample of U.S.
households with two or more members, based on the Current
Population Survey (CPS) definition of family. Because of nearuniversal Medicare coverage of the senior population, we
excluded families where every member was 65 or older.
Principal Findings: While 17.5% of U.S. residents under age
65 were uninsured in 2002, we found that 30% of all nonelderly families had an uninsured member. This difference
can be explained by the fact that the bulk of uninsured families
have at least one member with health insurance coverage. In
only 7% of U.S. families is every member uninsured. The
characteristics of uninsured families are generally comparable
to those of uninsured individuals (lower income and
education, poorer health, unmarried, racial/ethnic minority).
However, we find some differences in the characteristics
associated with being fully versus partially uninsured. For
example, partially uninsured families are much more likely to
be headed by someone who has retired or is out of the labor
force, compared to fully uninsured families. Among families
with at least one uninsured member, only 22% are fully
uninsured, while 78% have at least one member with health
insurance coverage. The most common source of coverage is
private insurance (35% of uninsured families), followed by
Medicaid or SCHIP (19%). Fourteen percent of uninsured
families have at least one member with Medicare, while 10%
have a blend of public and private coverage. Multivariate
modeling is underway to determine the independent
contribution of specified characteristics to a family's predicted
insurance coverage mix.
Conclusions: Our findings on family insurance coverage
suggest that the uninsured problem in the United States is
understated if we only measure coverage at the individual
level. While fewer than 20% of non-elderly individuals are
uninsured, nearly one in three families has at least one
member that lacks coverage. The most common source of
coverage for partially uninsured families is private insurance,
although this group represents only one-third of all uninsured
families. Further research is needed to determine if uninsured
members of these families are ineligible for this private
coverage, or if the cost of dependent coverage is prohibitively
high. Additionally, the relatively high rate of Medicaid/SCHIP
coverage among uninsured families (19%) suggests that
expanding coverage for Medicaid-eligible individuals to their
entire families could substantially reduce the uninsured
population.
Implications for Policy, Delivery, or Practice: In an era
where comprehensive health reform is unlikely, this study will
assist policymakers interested in incremental strategies for
reducing the uninsured. By understanding within-family
patterns of health insurance coverage, policymakers can
develop expansion strategies that build on current health
insurance arrangements (e.g. by subsidizing dependent
coverage or expanding public coverage to families). In this
way, resources can be targeted so that they achieve the
greatest coverage increases while supporting the development
of cohesive family insurance units.
Primary Funding Source: HRSA, Office of Rural Health Policy