Employment-based Health Insurance Research Articles

Horizontal and vertical equity and public subsidies for private health insurance in the U.S.

The United States offers two markedly different subsidy structures for private health insurance. When covered through employer-based plans, employees and their dependents benefit from the exclusion from taxable income of the premiums. Individuals without access to employer coverage may obtain subsidies for Marketplace coverage. This paper seeks to understand how the public subsidies embedded in the privately financed portion of the U.S. healthcare system impact the payments families are required to make under both ESI and Marketplace coverage, and the implications for finance equity.Using the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) and Marketplace premium data, we assess horizontal and vertical equity by calculating public subsidies for and expected family spending under each coverage source and using Lorenz curves and Gini and concentration coefficients. Our study pooled the 2018 and 2019 MEPS-HC to achieve a sample size of 10,593 observations. Our simulations showed a marked horizontal inequity for lower-income families with access to employer coverage who cannot obtain Marketplace subsidies. Relative to both the financing of employer coverage and earlier Marketplace tax credits, the more generous Marketplace premium subsidies, first made available in 2021 under the American Rescue Plan Act, substantially increased the vertical equity of Marketplace financing. While Marketplace subsidies have clearly improved equity within the United States, we conclude with a comparison to other OECD countries highlighting the persistence of inequities in the U.S. stemming from its noteworthy reliance on employer-based private health insurance.

Epidemiology and Risk Factors of Eosinophilic Esophagitis in Japan: A Population-Based Study

Background and AimsEosinophilic esophagitis (EoE) has been increasingly diagnosed globally. However, there have been few general population-based studies in Asia. The aim of this study was to investigate EoE epidemiology in the Japanese general population. MethodsWe analyzed an employer-based health insurance claim database from January 2005 to September 2022. EoE cases were identified based on the International Classification of Diseases-tenth Revision code, K20.0. We calculated the incidence and prevalence of EoE using Poisson regression and binomial distribution, respectively. Using 10 matched controls for each EoE case, a nested case-control study was performed to identify potential risk factors for EoE. ResultsOf 15,200,895 individuals, 1,010 EoE cases were identified. The incidence and prevalence of EoE were 2.82 (95% CI 2.44–3.26) per 100,000 person-years and 10.68 (95% CI 10.01–11.37) per 100,000 people in 2022, nearly three and eight times as high as those in 2017, respectively. Smoking was associated with decreased risk of EoE (OR 0.45 (0.36 to 0.56), p<0.001) whereas alcohol consumption (OR 1.51 (1.21 to 1.88), p<0.001) were associated with increased risk of EoE along with several allergic conditions and psychiatric disorders. EoE was not related to either body mass index or lifestyle-related diseases such as hypertension, diabetes mellitus, hyperuricemia, and dyslipidemia. ConclusionThe incidence and prevalence of EoE in Japan have steadily increased over the past two decades. Nevertheless, EoE remains less common in Japan compared to the United States and Western Europe. Factors contributing to the epidemiology of EoE on a global basis may improve our understanding of the contribution of genetic and environmental risk factors.

The Vexing Problem of Access to Health Care in America: Is Employer-Based Health Insurance the Real Culprit?

The Vexing Problem of Access to Health Care in America: Is Employer-Based Health Insurance the Real Culprit?

Site of Ambulance Origination and Billing for Out-of-Network Services

The No Surprises Act implemented in 2022 aims to protect patients from surprise out-of-network (OON) bills, but it does not include ground ambulance services. Understanding ground ambulance OON and balance billing patterns from previous years could guide legislation aimed to protect patients following ground ambulance use. To characterize OON billing from ground ambulance services by evaluating whether OON billing risk differs by the site of ambulance origination (home, hospital, nonhospital medical facility, or scene of incident). Cross-sectional study of the Merative MarketScan dataset between January 1, 2015, and December 31, 2020, using claims-based data from employer-based private health insurance plans in the US. Participants included patients who utilized ground ambulances during the study period. Data were analyzed from June to December 2023. Medical encounter requiring ground ambulance transportation. Ground ambulance OON billing prevalence was calcuated. Linear probability models adjusted for state-level mixed effects were fit to evaluate OON billing probability across ambulance origins. Secondary outcomes included the allowed payment, patient cost-sharing amounts, and potential balance bills for OON ambulances. Among 2 031 937 ground ambulance services (1 375 977 unique patients) meeting the inclusion and exclusion criteria, 1 072 791 (52.8%) rides transported men, and the mean (SD) patient age was 41 (18) years. Of all services, 1 113 676 (54.8%) were billed OON. OON billing probabilities for ambulances originating from home or scene were higher by 12.0 percentage points (PP) (95% CI, 11.8-12.2 PP; P < .001 for home; 95% CI, 11.7-12.2 PP; P < .001 for scene) vs those originating from hospitals. Mean (SD) total financial burden, including cost-sharing and potential balance bills per ambulance service, was $434.70 ($415.99) per service billed OON vs $132.21 ($244.92) per service billed in-network. In this cross-sectional study of over 2 million ground ambulance services, ambulances originating from home, the scene of an incident, and nonhospital medical facilities were more likely to result in OON bills. Legislation is needed to protect patients from surprise billing following use of ground ambulances, more than half of which resulted in OON billing. Future legislation should at minimum offer protections for these subsets of patients often calling for an ambulance in urgent or emergent situations.

Optimal reimbursement limitation for a health plan

AbstractThe goal of this paper is the assessment of an optimal reimbursement strategy for employer-based health insurance plans (HP), that cover several categories of medical services. Indeed, a health plan may offer several cost-sharing provisions for these categories, and the “Percent Expense Paid” by the plan also known as “Actuarial Value” represents a summary measure of the protection provided. Starting from a wide industrial applied model in insurance for rate-making, the generalized linear models (GLM), we estimate the expected value and variance of the health expenditure for each category. Moreover, different reimbursement rules (e.g. deductibles, co-payments, policy limits, etc.) involve a change of the “Actuarial Value” calculated as the ratio between the benefits paid by the plan (i.e. reimbursement amounts) and the expenses paid by policyholders (i.e. expenditures). The latter is the percentage of expenditure reimbursed by the plan and is sometimes defined in actuarial literature as Indicated Deductible Relativity (IDR); an IDR can be calculated for each category covered by the Health Plan or per policyholder and is a commonly used method for scoring the benefits of health insurance. Hence, we calculate the optimal IDR for each category, using the optimization problem proposed by de by Finetti (Il problema dei pieni, Giornale dell’istituto italiano degli attuari, 1940) in the context of proportional reinsurance. The goal is the minimization of the variance of the total reimbursement of the Health Plan by fixing the total gain. Furthermore, we propose a numerical application to a real dataset, containing observed expenditures of an Italian HP.

Effectiveness of Specific Health Check-ups in Japan for the primary prevention of obesity-related diseases: a protocol for a target trial emulation

IntroductionConcerns about public health threats have shifted towards obesity-related, non-communicable diseases in both developed and developing countries. Since 2008, Japan has adopted a nationwide universal screening programme called Specific Health...

A Profile of the Direct Care Workforce in Home- and Community-Based Services.

We used data from the 2020 American Community Survey to compare direct care workers (DCWs) in home and community-based services (HCBS) with workers in other long-term supportive services (LTSS), such as skilled nursing facilities (SNFs) and assisted living facilities (ALFs). Compared to DCWs in SNFs and ALFs, a higher proportion of DCWs in HCBS were over age 65, Latino/a, and single. A lower proportion of DCWs in HCBS worked for a for-profit company, worked year-round and full-time, and had employer-based health insurance.

Universal cash transfers and prescription utilization: Evidence from the Alaska permanent fund dividend

We investigate the impact of a large cash transfer on prescription utilization. Our identification strategy leverages the Alaksa Permanent Fund Dividend (PFD), which is distributed annually in October and comprises 6% of the average household's annual income. We study the impact of the PFD on the use of prescription medications using a within-Alaska comparison group and difference-in-differences design. Using the IBM MarketScan Commercial Claims and Encounters Prescription Drug Database, we observe prescriptions for 50,866 commercially-insured individuals who filled prescriptions between 2013 and 2019. We find no changes in prescription use overall and are able to rule out changes larger than 0.5% in the week of the PFD and 1.4% the week after. Subgroup analyses find no changes by patient characteristics, degree of cost sharing, or prescription type. We also conduct a synthetic control analysis using a non-Alaska comparison group and find no effects of the PFD on prescriptions. These findings are useful for understanding liquidity sensitivity for prescription medication and the effects of cash distributions among individuals with employer-based health insurance.

Employer-Based Health Insurance and Employee Compensation

This Viewpoint expounds on how the cost of health insurance is consuming an ever-greater share of total compensation for employers and employees, stagnating real incomes and calling into question its real value.

THE IMPACT OF RACE AND GENDER ON OVERALL CARE RATING AT THE END OF LIFE: APPLYING THE THEORY OF INTERSECTIONALITY

Abstract Research focused on the quality of care received at the end of life has advanced over the past few decades, but few studies have employed an intersectional lens to assess differences in care quality. The theory of intersectionality suggests that individuals with membership in two or more vulnerable groups may be at risk of experiencing increased hardships and stressors across the lifespan. To test the theory of intersectionality and fill the gap in research, this study aimed to assess the combined impact of race and gender on the quality of care received at the end of life among older adults. Data were derived from the combined Round 3 to Round 10 of the National Health and Aging Trends Study, an annual longitudinal panel survey of adults aged 65 and older in the United States. Chi-square tests were used for bivariate analyses and two multivariate logistic regressions were run. Results showed that White men were the most likely to have had excellent or good care at the end of life, followed by White women, Black men, and then Black women. This points to a significant disadvantage for Black women, who lag behind all other groups in other life domains such as income, education, and access to health insurance. Interventions may include intersectionality-focused cultural humility training, cultural matches between patients and providers, and the adoption of a universal health insurance plan to reduce the gaps in service quality caused by the dominance of employment-based health insurance in the United States.

POETRY AND UNCOVERING THE MYSTERY OF SOCIAL PROBLEMS: AN ARTS-BASED INQUIRY TO AGING CARE

Abstract This research focuses on a current social welfare problem: unemployment and the loss of employer-based health insurance among non-elderly adults aged 18 to 64. The literature covers this social problem in terms of health status, access to medical care, employed versus unemployed working-age adults, mitigating the risks of unemployment, and loss of health insurance via the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As good as the findings are, they are methodologically limited by looking at only half the story. This research asks a different question: how might the humanities and arts-based perspective address the social problem? It aims at answering why the employment status is related to health and health insurance. Chinese poetry has a long rich tradition of expressing insights about the inner life since antiquity to the present. These reflections include practice wisdom and keen observations on aging. This poster presents case findings on the use of Chinese poetics to inform aging care in the West. Each case provides discussions on why social welfare system comes up short to solve the problem and how the social welfare system can be effectively changed. Researchers use survey data to compliment Chinese poetic insights about employment status and insurance status to illustrate the correlation between respondents’ health status with versus without employment. Findings are hoped to interpret the role of family as a social unit where it consists in social welfare along with the speculative inquiry of poetry.

Labor-Market Concentration and Labor Compensation

This article estimates the effect of labor-market concentration on labor compensation across the US private sector since 2000. The authors distinguish between concentration in local labor markets and local product markets while guarding against bias from confounded product-market concentration. The analysis extends beyond wages to rates of employment-based health insurance coverage. Reported results suggest negative effects of labor-market concentration on labor compensation. These effects are exacerbated when product-market concentration is higher or when workers are older.

Prevalence of comorbidities associated with sickle cell disease among non-elderly individuals with commercial insurance-A retrospective cohort study.

Sickle cell disease (SCD) is a severe monogenic disease associated with high morbidity and mortality and a disproportionate burden on Black communities. Few population-based studies have examined the prevalence of comorbidities among persons with SCD. We estimated the prevalence of comorbidities experienced by individuals with SCD enrolled in employer-based health insurance plans in the US over their non-elderly lifetimes (0-64 years of age) with a retrospective cohort design using Truven Health MarketScan commercial claims data from 2007-2018. ICD-9/10 codes were used to identify individuals with SCD using a previously published algorithm. For this cohort, comorbidities associated with SCD were identified across 3 age categories (<18, 18-45, 46-64 years-old), based on the CMS Chronic Comorbidities Warehouse or SCD-specific diagnosis codes, when applicable. The total number of SCD patients available for analysis in each age category was 7,502 (<18 years), 10,183 (18-45 years) and 4,459 (46-64 years). Across all ages, vaso-occlusive pain, infections (non-specific), and fever were the most common comorbidities. Vaso-occlusive pain and infection were the most prevalent conditions for persons age <18- and 18-45-year-olds, while in the 46-54-year-old age group, infection and cardiovascular including pulmonary hypertension were most prevalent. Compared to persons <18 years old, the prevalence of vaso-occlusive pain, fever, and acute chest syndrome claims declined in older populations. The comorbidity burden of SCD is significant across all age groups. SCD patients experience comorbidities of age such as chronic pain, cardio-vascular conditions including pulmonary hypertension and renal disease at far higher rates than the general population. Novel disease modifying therapies in development have the potential to significantly reduce the comorbidity burden of SCD.

Association of dipeptidyl peptidase-4 inhibitor use and risk of pancreatic cancer in individuals with diabetes in Japan.

This study was designed and carried out to investigate the association of dipeptidyl peptidase-4 inhibitor (DPP-4i) use with pancreatic cancer (PC) in individuals with diabetes in Japan. The JMDC Claims Database, which contains the medical and prescription information of Japanese employment-based health insurance programs, was used. The primary outcome was duration to the first occurrence of PC (International Classification of Diseases 10th Revision code C25), both all and hospitalized, from prescription of DPP-4is or other oral glucose-lowering agents (GLAs). Individuals with diabetes who received DPP-4is (n= 61,430) or other oral GLAs (n= 83,304) were analyzed. Follow-up periods (median [interquartile range]) were 17 months (8-33) for DPP-4is and 14 months (7-28) for other oral GLAs. Kaplan-Meier curve analysis to determine the duration of first use of DPP4i or other oral GLA to diagnosis of PC disclosed no differences between the two groups in duration to all or hospitalized PC (log-rank test: all, P= 0.7140; hospitalized, P= 0.3446). Cox proportional hazards models showed that use of DPP-4is did not affect the PC risk adjusted for medications, age, sex and risk comorbidities (all, hazard ratio 1.1, 95% confidence interval 0.8-1.3, P= 0.6518; hospitalized, hazard ratio 1.1, 95% confidence interval 0.8-1.4, P= 0.6662). Similar results were obtained when individuals with ≥2 years oral GLA treatment and those with medical checkup data (e.g., smoking or drinking habit) available were analyzed. This database study shows that there is not a significant PC risk due to DPP-4i treatment in individuals with diabetes in Japan, but larger studies with longer follow up are required to confirm these findings.

The Affordable Care Act and Women’s Self-Employment in the United States

The United States’ Affordable Care Act (ACA) of 2010 improved and expanded availability of non-group health insurance. Previous studies have shown that women in the US workforce value health insurance more highly than men do. Because prior to the ACA self-employed individuals did not have guaranteed access to affordable health insurance coverage, women’s relatively lower rate of self-employment may partly have reflected their greater “job lock” due to employer-based health insurance. This article employs nationally representative survey data for 2009–18 and a quasi-experimental difference-in-difference modeling approach and finds that unmarried women’s probability of self-employment increased by 1.2 percentage points in 2015–18, after the ACA’s expansion of non-group health insurance came into effect. Among women who have never married, overall probability of self-employment increased by 1.2–1.5 percentage points versus trend, and the probability of transitioning into full-time self-employment increased by 0.9 percentage points. HIGHLIGHTS In the US, unmarried women are less likely than men to be self-employed. The Affordable Care Act improved access to non-employer-based health insurance, reducing the cost of leaving jobs. As a result, from 2015–2018, unmarried women were increasingly drawn to self-employment. The ACA’s expansion of health insurance thus provides important economic benefits beyond healthcare access.

Retirement behavior of cancer survivors and the role of employer-sponsored health insurance.

222 Background: Workers who rely on employment for health insurance may choose to continue working following a serious health condition, potentially harming their health in retirement. In this study, we examine the influence of retiree and employment-contingent insurance on retirement behavior and health of workers diagnosed with cancer. Methods: This longitudinal cohort study used 2000-2018 Health and Retirement Study data to examine changes in employment, weekly hours worked, and health status measures following a cancer diagnosis by health insurance status. We selected respondents who reported a new cancer diagnosis (n = 354) and a matched, non-cancer sample (n = 1,770 respondents), restricting both samples to those employed and younger than age 63. Results: Women with cancer and retiree health insurance were 21.0 percentage points less likely to work (95% CI: –38.5 to –3.5; p &lt; 0.05) relative to women with employer health insurance, but no retiree insurance. Employed women with cancer but no health insurance increased weekly hours worked by 32% relative to similar non-cancer controls. Men and women with a new cancer diagnosis and without health insurance were also less likely to work (p &lt; 0.05). Respondents with employer-based health insurance reported better subsequent health status than respondents without health insurance from their employer. Conclusions: Cancer survivors with both employer insurance and retiree health insurance are able to leave the workforce earlier, and report better health status when they stop working following a cancer diagnosis.

Prevalence, incidence, and medications of narcolepsy in Japan: a descriptive observational study using a health insurance claims database

The objectives of this study were to describe prevalence, incidence, and medications among patients who were diagnosed with narcolepsy in Japan using a claims database. Patients diagnosed with narcolepsy were identified from January 2010 to December 2019 using an employment-based health insurance claims database compiled by JMDC Inc. The prevalence and incidence of narcolepsy were estimated annually in the overall population and by age and sex among employees and their dependents aged < 75 years. Medications, examined for each quarter in the overall population, were modafinil, methylphenidate, pemoline, tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors. We identified 1539 patients with narcolepsy. The overall annual prevalence increased from 5.7 to 18.5/100,000 persons in 2010 and 2019, respectively. Large increases were found from 2010 to 2019 in patients aged 20–29 years and 10–19 years, with the highest prevalence in 2019 (9.7–37.5/100,000 persons and 5.0–27.1/100,000 persons). The overall incidence slightly increased from 3.6 to 4.3/100,000 person-year from 2010 to 2019, and the highest incidence was found in patients aged 20–29 years and 10–19 years (5.8–11.3/100,000 person-year, and 3.8–7.4/100,000 person-year from 2010 to 2019, respectively). Methylphenidate and modafinil were commonly prescribed in 2010 (27.3–38.9% and 17.5–45.5%, respectively). Methylphenidate prescriptions declined during the 10 years, whereas modafinil prescriptions increased (15.6–17.1% and 43.8–45.8% in 2019, respectively). The estimated prevalence and incidence of narcolepsy appeared to increase from 2010 to 2019, especially in teenagers and 20-year olds.

Willingness to Pay for Employment-Based Health Insurance: A Study among Government Employees in Qassim Region, Saudi Arabia

Currently, government employees in Saudi Arabia receive free healthcare services from the public healthcare system. Moreover, health services are provided to private-sector employees through mandatory cooperative health insurance of the employer. In the future, the government plans to introduce employment-based health insurance for those working in the public sector. In this research, the willingness of those working in the public sector to pay for employment-based health insurance has been examined. We interviewed 1230 participants from Qassim region using an auto-administration online questionnaire from February 3^rd to February 28^th, 2022. Altogether, 49.6% of participants reported that they would be willing to pay (WTP) for employment-based health insurance, with a mean monthly contribution of SAR 166.47 (US$.44.4) per family. Moreover, the findings of this research revealed that participants' willingness to pay for health insurance is impacted by a number of socioeconomic factors including age, gender, household size, prevalence of chronic diseases in the family, possession of private health insurance policies, and satisfaction with healthcare (p<0.05). The findings of this research can serve to help policymakers develop employment-based health insurance initiatives with acceptable premiums.

Chronic patients as retirement-aged workers: the impact of employment-based health insurance and chronic conditions on health-related working capacity and late-life career participation.

Retirement-aged workers with chronic conditions are increasingly engaged in late-life careers in the policy context of delayed retirement initiative. However, it remains uncertain as to how chronic conditions and employment-based social health insurance interact to affect health-related working capacity and late career participation in this group of people. Using data from the China Health and Retirement Longitudinal Study (CHARLS) and the discrete choice model, this study finds that chronic conditions are negatively associated with health-related working capacity (- 0.400, p < 0.01) and late-life career participation (- 0.170, p < 0.01). Employment-based health insurance is positively associated with health-related working capacity of retirement-aged workers (0.432, p < 0.01), but is negatively associated with their late-life career participation (- 1.027, p < 0.01). Moreover, employment-based health insurance could weaken the negative associations between chronic conditions and health-related working capacity (interaction = 0.285, p < 0.05) and late-life career participation (interaction = 0.251, p < 0.05). More fine-grained policies for delayed retirement are needed to focus on the long-neglected health of retirement-aged workers with chronic conditions.

Navigating job and cancer demands during treatment: A qualitative study of ovarian cancer patients

ObjectiveOur objective was to obtain perspectives from ovarian cancer patients on job demands, cancer demands, and workplace or cancer resources and strategies to manage the cancer-work interface using the cancer-work management conceptual framework. MethodsWe recruited ovarian cancer patients receiving systemic therapy who screened positive for financial distress using Comprehensive Score for Financial Toxicity <26. Interviews were conducted with participants about their costs of care, including employment concerns. Interviews were recorded, transcribed verbatim, and analyzed by three researchers using an inductive thematic analysis. ResultsOf 22 participants, the average age was 57 years old, 36% were Black, 68% had income <$40,000, 41% had public insurance, and 68% were being treated for recurrent disease. Job demands included decreased productivity, inability to return to work, and worry about losing a job or employer-based health insurance coverage. Cancer demands included physical and cognitive limitations due to cancer treatment and reliance on caregivers, especially for transportation. Workplace resources/strategies including having a supportive employer, modifying job responsibilities, and utilizing family medical leave. Cancer care resources/strategies included planning appointments ahead of time and utilizing resources, such as disability. ConclusionsCancer care teams should consider screening patients for employment concerns; streamline care to minimize the side effects, time, and transportation demands of treatment on patients and caregivers; maximize utilization of available resources; and proactively communicate with employers to accommodate patients and caregivers who want or need to work.