Public Insurance

The dynamics of health care delivery for children and adolescents have greatly evolved over the last 5 years. The growth of managed care has been especially rapid, and has coincided with other fundamental changes—declines in private coverage, growth of Medicaid, welfare reform, and the creation of the state Child Health Insurance Program (CHIP).1 Over the past 10 years, the number of children covered through employer-sponsored plans and other private plans has dropped.2 During this same period, changes to Medicaid have begun to de-couple eligibility from welfare eligibility, theoretically enabling states to expand coverage. For children, this movement from private to public coverage has accelerated the movement to managed care systems. Between 1991 and 1997, Medicaid enrollment in managed care plans increased from 9.5% to 47.8% of total Medicaid enrollment.3 Recent estimates suggest that over half of these Medicaid managed care enrollees are children.4 However, little is known about the impact of these trends on children's access to and use of services, let alone the quality and outcomes of that care. This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of 2 national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, we have provided a detailed description of the datasets, and review some of the fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues. ### MEPS The MEPS is conducted to provide nationally representative estimates of health care use, …

Objective-Discontinuities in health insurance coverage may make it difficult for individuals early in psychosis to receive the services that are critical in determining long-term outcome.This study reports on the rates and continuity of insurance coverage among a cohort of early-psychosis patients enrolled in Specialized Treatment Early in Psychosis (STEP) at the Connecticut Mental Health Center.Methods-Insurance status at baseline, six months, and 12 months was collected from 82 participants from a combination of self-reports, clinical chart review, clinician reports, and a database maintained by the state Department of Social Services.Results-A total of 34 participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months.Among the remaining 48 participants, at baseline 18 had private insurance, 13 had public insurance, and 16 had no insurance.

Disparities in access to care and transplantation outcomes, including prolonged waitlist times and reduced living donor transplantation rates, are well-documented in Hispanic kidney transplant patients. While post-transplant graft and patient survival rates are generally comparable to those of non-Hispanic white patients, variability within the Hispanic population is driven by socioeconomic and clinical factors. Insurance type may be a crucial determinant of both access to transplantation and post-transplantation outcomes, warranting a focused study of its impact within this population. We used the OPTN/UNOS database to identify Hispanic kidney-only transplant recipients in the United States between 2015 and 2019. We categorized patients by insurance type to public versus non-public insurance. We compared risk of graft failure and death after kidney transplant between the public and non-public insurance groups. Of 14,639 Hispanic kidney transplant recipients, 10,761 (74%) had public insurance. Public insurance group were older, had more kidney retransplant, more deceased donor but less preemptive kidney transplant, longer dialysis duration, more diabetes, peripheral vascular disease, reduced functional status, and were less likely to be employed or have high education level compared to non-public insurance group. Public insurance was significantly associated with an increased risk of death-censored graft failure (HR 1.36; 95% CI 1.16–1.60) and patient death (HR 1.15; 95% CI 1.01–1.30). Similarly, public insurance was significantly associated with an increased risk of graft failure when accounting for death as the competing risk. Disparities in post-transplant outcomes were observed between Hispanic kidney recipients with public versus non-public insurance. Public insurance was a significant predictor for reduced graft and patient survival after kidney transplant.

Public Insurance As a Proxy Measure of Household Poverty-Exposures Among Children with Hematologic Malignancies

Although insurance status has been linked to surgical outcomes in thoracic aortic operations, its specific association with the outcomes of Type A Aortic Dissection (TAAD) repair remains underexplored. This study aimed to conduct a comprehensive, population-based analysis to assess the association between insurance status and in-hospital outcomes after TAAD repair using a national registry.Patients who underwent TAAD repair were identified in National Inpatient Sample from the last quarter of 2015 to 2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients using public and private insurance while adjusting for demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status.There were 2,380 (55.58%) and 1,468 (34.28%) patients under public and private insurance, respectively. Patients under public and private insurance had comparable time from admission to operation (p = 0.08) and adjusted in-hospital mortality rates (aOR = 1.172, 95 CI = 0.925-1.484, p = 0.19). However, patients under public insurance had higher mechanical ventilation (aOR = 1.185, 95 CI = 1.024-1.373, p = 0.02), acute kidney injury (aOR = 1.213, 95 CI = 1.052-1.399, p = 0.01), and infection (aOR = 1.428, 95 CI = 1.087-1.876, p = 0.01). Moreover, patients under public insurance had higher transfer-out rate (p < 0.01), longer length of stay (p < 0.01), and higher total hospital charge (p < 0.01).Although patients with public insurance had comparable adjusted mortality outcomes to those of privately insured patients, they experienced higher rates of postoperative complications and resource utilization. Future studies should investigate the underlying systemic reasons for these disparities and explore strategies for improving surgical outcomes and ensuring equitable healthcare delivery for these vulnerable populations.

This paper documents the changing picture of health insurance coverage for pregnant women in the four-year period following Medicaid expansion and assesses the extent to which the crowding-out phenomenon may have influenced the observed trends. The report documents the distribution of insurance coverage for pregnant women in the post-expansion period and describes demographic characteristics of women covered under Medicaid. It examines the rate at which Medicaid-eligible women enroll in the program and addresses the crowding-out issue by comparing the trend in employer-sponsored coverage among poor and near-poor pregnant women with those among nonpregnant women and men of similar ages and incomes.

Background:Pediatric and adolescent patients who undergo shoulder stabilization surgery have higher rates of failure than their adult counterparts. The impact of insurance status on intra-operative findings and outcomes is largely unknown.Hypothesis/Purpose:We hypothesized that patients with public insurance who undergo shoulder stabilization surgery would have greater degrees of bony pathology; leading to poor outcomes after stabilization.Methods:This was a retrospective cohort study of pediatric and adolescent patients with public and private insurance who were treated for recurrent shoulder instability from 2011-2017. Patients were treated at a tertiary care children’s hospital by a single orthopaedic surgeon. Patients 10 to 18 years of age were included in the study if they presented with recurrent shoulder instability and underwent surgical intervention for their injury. Time from injury to clinical consultation, imaging, and surgical intervention; incidences of labral pathology and secondary bony injury; and rates of repeat dislocation and repeat surgery were compared between the public and private insurance cohortsResults:Thirty-seven patients had public insurance while 18 patients had private insurance. Privately insured patients were evaluated by clinicians nearly five times faster than were publicly insured patients (p < 0.001), and they obtained MRIs over four times faster than did public insurance patients (p < 0.001). Publicly insured patients were twice as likely to have secondary bony injuries (p=0.043). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced re-dislocation versus the complete absence of re-dislocation in the privately insured patients (p=0.022).Conclusion:Public insurance status impacts access to care and correlates with both the development of secondary bony injury and an increased rate of clinical failure manifested as repeat post-operative dislocations.Table 1.Data SummaryAll (n=55)Public Insurance (n=37)Private Insurance (n=18)Days from Injury to Clinic298.71402.3885.61Days from Injury to MRI323.04431.9799.11Days from Injury to Surgery451.76561.38226.44*Days from Clinic to MRI24.3329.5913.50*Days from MRI to Surgery128.73129.41127.33Number of prior dislocationsNone = 3Single = 2Multiple = 32None = 6Single = 0Multiple = 12Incidence of anterior only vs. complex labral pathologyAnterior only = 81.8% (45/55)Complex = 18.2% (10/55)Anterior only = 83.8% (31/37)Complex = 16.2% (6/37)Anterior only = 77.8% (14/18)Complex = 22.2% (4/18)Incidence of bony involvement (Y/N)56.4% (31/55)67.6% (25/37)33% (6/18)Incidence of repeat dislocations16.4% (9/55)24.3% (9/37)0.00% (0/18)*Incidence of repeat surgery5.5% (3/55)8% (3/37)0.00% (0/18)Table 1 shows the summary of results for public and private insurance cohorts for days from injury to clinic, injury to MRI, injury to surgery, clinic to MRI, MRI to surgery as well as number of prior dislocations, incidence of anterior only vs. complex labral pathology, incidence of bony involvement, incidence of repeat dislocations, and incidence of repeat surgery. * denotes that the difference between the two insurance cohorts was not statistically significant.

1191-P: Social Determinants of Health Barriers—Differences between Public vs. Private Insurance

The welfare associated with public insurance is often difficult to quantify. Relative to private insurance, a fundamental difficulty is that public insurance is typically compulsory, so the demand for coverage is unobserved and thus cannot be used to analyze welfare. However, in many public insurance settings, individuals can purchase private insurance to supplement their public coverage. In this paper, we outline an approach to use data and variation from private complementary insurance to quantify welfare associated with several counterfactuals related to compulsory public insurance. Using administrative data from one large firm on employee long-term disability insurance, we then apply this approach empirically to quantify the value of disability insurance among this population. We use premium variation among the employer-provided disability policies to quantify the surplus that would be generated by increasing the replacement rate of disability insurance for our sample population ― a counterfactual that is within the set of insurance contracts observed in this setting. In addition, we estimate a lower bound on the surplus generated by public disability insurance in this context. Our findings suggest that public disability insurance generates substantial surplus for this population, and there may be gains to increasing the generosity of coverage in this context.

Disagreements Over Federal Investment Could Be Obstacle to Health Reform

The welfare associated with public insurance is often difficult to quantify. Relative to private insurance, a fundamental difficulty is that public insurance is typically compulsory, so the demand for coverage is unobserved and thus cannot be used to analyze welfare. However, in many public insurance settings, individuals can purchase private insurance to supplement their public coverage. In this paper, we outline an approach to use data and variation from private complementary insurance to quantify welfare associated with several counterfactuals related to compulsory public insurance. Using administrative data from one large firm on employee long-term disability insurance, we then apply this approach empirically to quantify the value of disability insurance among this population. We use premium variation among the employer-provided disability policies to quantify the surplus that would be generated by increasing the replacement rate of disability insurance for our sample population---a counterfactual that is within the set of insurance contracts observed in this setting. In addition, we estimate a lower bound on the surplus generated by public disability insurance in this context. Our findings suggest that public disability insurance generates substantial surplus for this population, and there may be gains to increasing the generosity of coverage in this context.

The purpose of this study was to examine associations between clinical and demographic characteristics of depressed patients and source of payment for care. We attempted to confirm and extend findings from a previous study regarding the first 1500 participants enrolled in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study with 2541 participants enrolled in later stages of the trial. Demographic, clinical, and presenting symptom features were compared among participants with public, private or no insurance. Compared to those having private or no insurance, participants with public insurance were older; more likely to be women, Hispanic, widowed or divorced, unemployed, and less educated; were more frequently seen in primary care; had greater medical comorbidity and functional impairment, and a later age of depression onset. The publicly insured also had a longer current episode, but fewer episodes over their lifetime. Both the publicly insured and the uninsured had poorer life satisfaction compared to those with private insurance. Participants without insurance were intermediate between those with public and private insurance regarding several demographic characteristics and measures of severity. Depressed outpatients with public insurance demonstrated greater functional impairment, though they did not have a more severe depression per se. Participants without insurance seemed to be a heterogeneous group with a presentation intermediate between those with public and private insurance. Those with public insurance were overrepresented in primary care clinics; therefore, clinicians in these settings need to be particularly vigilant in recognizing depression and offering appropriate treatments.

There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.

BackgroundChina is reforming and restructuring its health insurance system to achieve the goal of universal coverage. This study aims to understand the determinants of public, private and multiple insurance coverage among people of retirement-age in China.MethodsWe used data from the China Health and Retirement Longitudinal Survey 2011 and 2013, a nationally representative survey of Chinese people aged 45 and over. Multinomial logit regression was performed to identify the determinants of public, private and multiple health insurance coverage. We also conducted logit regression to examine the association between public insurance coverage and demand for private insurance.ResultsIn 2013, 94.5% of this population had at least one type of public insurance, and 12.2% purchased private insurance. In general, we found that rural residents were less likely to be uninsured (Relative Risk Ratio (RRR) = 0.40, 95% Confidence Interval (CI): 0.34–0.47) and were less likely to buy private insurance (RRR = 0.22, 95% CI: 0.16–0.31). But rural-to-urban migrants were more likely to be uninsured (RRR = 1.39, 95% CI: 1.24–1.57). Public health insurance coverage may crowd out private insurance market (Odds Ratio = 0.55, 95% CI: 0.48–0.63), particularly among enrollees of Urban Resident Basic Medical Insurance. There exists a huge socioeconomic disparity in both public and private insurance coverage.ConclusionThe migrants, the poor and the vulnerable remained in the edge of the system. The growing private insurance market did not provide sufficient financial protection and did not cover the people with the greatest need. To achieve universal coverage and reduce socioeconomic disparity, China should integrate the urban and rural public insurance schemes across regions and remove the barriers for the middle-income and low-income to access private insurance.

The authors sought to describe the epidemiology of and risk factors for recurrent and high-frequency use of the emergency department (ED) by children. This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p<0.001). High-frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.