Expanding Health Care Research Articles

Impacts of Expanding Health Care Coverage on the Employment and Earnings of Participants in the SSI Work Incentive Program - Policy Brief

While people with disabilities often say that a loss of public health insurance is a deterrent to work, it is rare to find situations in which they might actually exhibit such a behavioral response to a change in access. Expansions in the income threshold for SSI work incentives program (Sections 1619(a) and (b)) provide an opportunity to observe such a response. Section 1619(b) allows SSI recipients to maintain Medicaid eligibility even if their income is above the level that makes them ineligible for SSI payments. If earnings increase beyond the 1619(b) threshold, however, the person loses their SSI and Medicaid eligibility. Section 1619(b) income thresholds vary significantly across states and over time. Stapleton and Tucker (2000) use the variation in Section 1619(b) income thresholds to examine the employment, earnings and program participation patterns of SSI recipients who have incomes near the threshold level for their state. They find strong evidence that many SSI recipients restrain their earnings to stay below the 1619(b) threshold. It is important to note, however, that the findings only provide evidence on the behavior of a small portion of the population with disabilities (i.e., SSI recipients who work). Nonetheless, this evidence seems to provide strong empirical support for the hypothesis that lack of access to health insurance is an important work disincentive for people with disabilities. They also find that 1619(b) participation varies significantly from month to month. Consequently, cross-sectional estimates on the share of SSI recipients participating in 1619(b) significantly understate the share of SSI recipients who ever participate. These findings are consistent with previous findings that cross-sectional estimates of employment tend to understate multi-period employment patterns for the broader population with disabilities.

HSAs: More Than a (Tax) Shelter, Not Quite a House

Health savings accounts should not be the focus of a strategy to expand health care coverage to the uninsured, but should be considered complementary to more fundamental health care reform. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Physicians and advocacy

“We are presently in the situation where [we] are meeting with [senior government officials] to garner support for [Providence Health Care's expansion project] and we can now anticipate an irritated reception from them due to bad press attributed to PHC. It is absolutely essential that we get a

Learn How Latest Technology Can Transform Your Practice

Learn How Latest Technology Can Transform Your Practice

America's Meltdown: The Lowest Common Denominator Society

America's Meltdown: The Lowest Common Denominator Society John Boghosian Arden. Westport: Praeger, 2003. Contemporary narratives of social decline commonly originate from points of view hostile to egalitarianism, individualism, relativism, and secular humanism. Think of Allan Bloom's The Closing of American Mind (1987), Robert Bork's Slouching Toward Bethlehem (1996), and William Bennett's The Death of Outrage (1998). America's Meltdown, written by director of training for Department of Psychiatry at Kaiser Permanente in Vallejo, California, springs from more liberal impulses. Think of Bill McKibben's The End of Nature (1990) and Robert Putnam's Bowling Alone (2000). With a simplification that reminds one of shouting radio programs, John B. Arden conceptualizes presumed ongoing meltdown through all-purpose concept of the lowest common denominator (called LCD throughout). Arden never defines a literal descriptive or diagnostic content of this arithmetic-based metaphor, simply using it to condemn any lamentable social trend. The reader will quickly learn to think BAD/MUST STOP! whenever term appears. The elasticity of this monoconceptual approach will frustrate more pluralistically minded. What, then, is so bad about our social world? Without listing them all, current maladies include seductions of Internet, vicarious living through television, domestic terrorism, schoolhouse shootings, gun ownership, video games, gambling, spiritual supermarket religion, political soft money, and overly publicized sports. In diagnostic final chapter on Rebuilding Future, Arden calls for remvigoration by the basic principles of a healthy society, including compassion, tolerance, and flexibility (193). Other broad goals called for include responsible entertainment, real news, conservation, disarmament, expanded health care, and greater emphasis on prevention. The book's final sentence reads, A healthy future requires you to participate with others in constructing a society of clarity as usher in new millennium (212). Readers can learn some things from this book, which does range over numerous ideas and sources, but quality of scholarship will often frustrate desire to go further. The book does not attempt to synthesize best-known and documented treatments of its topics. For example, in attacking aggressive use of computers in early education, Arden fails to mention Clifford Stoll's best-selling Silicon Snake oil (1995). In discussing the spiritual supermarket, he fails to refer to Wade C. Roof's Spiritual Marketplace (1999) or Richard Cimino and Don Lattin's Shopping for Faith (1998). Because this book is about declining standards, one should not ignore its failure to meet expectations. One grammatical challenge on page 3 exposes a typical problem in book. Arden writes, we spend approximately a quarter of time socializing today [sic] did 35 years ago. If than is supposed to be relative, then there is a missing -which would mean that spend a quarter time less did. If than is a misprint for that, then would be spending a mere 25 percent of expended spent 35 years ago, or a drop of 75 percent. …

Enrolling children in the State Children's Health Insurance Program (S-CHIP): Can we do more?

Enrolling children in the State Children's Health Insurance Program (S-CHIP): Can we do more?

CMS Reflections: A Milestone For Medicare And Medicaid

Web Exclusives Health AffairsVol. 24, No. Suppl1: Web Exclusives CMS Reflections: A Milestone For Medicare And MedicaidPUBLISHED:2005No Accesshttps://doi.org/10.1377/hlthaff.W5.325AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions AbstractPROLOGUE:On 30 July 1965 President Lyndon B. Johnson signed laws establishing the Medicare and Medicaid programs (Titles 18 and 19 of the Social Security Act), the nation's first federally sponsored programs to finance health insurance with tax dollars. Medicare, the federally administered and financed health insurance program for the elderly and disabled, covers more than forty million people age sixty-five or older or with permanent disabilities; program expenditures were $283 billion in 2003. Medicaid, which offers health insurance to the disabled as well as to needy adults and children, is jointly funded by states and the federal government but is managed primarily by individual states. The program covers more than fifty million people, with combined state and federal expenditures now exceeding $300 billion.At the programs' inception, Medicare and Medicaid were administered separately—Medicare under the Social Security Administration and Medicaid under the Social and Rehabilitative Services Administration. In 1977 the Carter administration created the Health Care Financing Administration (HCFA), within the Department of Health, Education, andWelfare (HEW), to consolidate the administration of these two programs. HCFA is known today as the Centers for Medicare and Medicaid Services (CMS) and is part of the Department of Health and Human Services (HHS).Despite perennial fiscal pressures, both programs have expanded in the past decade, via the State Children's Health Insurance Program (SCHIP), which since 1997 has helped states expand health care coverage to the nation's uninsured children, and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which, among other things, will offer drug coverage to all Medicare beneficiaries for the first time in the program's history. To commemorate the forty-year anniversary of Medicare and Medicaid, Health Affairs invited former HCFA/CMS administrators to share their thoughts and reflections on the programs and the agency that administers them. We include here essays from HCFA's first administrator, Robert Derzon, followed by pieces from Leonard Schaeffer, Bill Roper, Gail Wilensky, Bruce Vladeck, Nancy-Ann DeParle, and Tom Scully. The publication of these papers coincides with a 26 July 2005 event in Washington, D.C., cosponsored by the Commonwealth Fund and the Henry J. Kaiser Family Foundation, also commemorating the anniversary. AWebcast of the event, titled “Medicare + Medicaid at 40,” is available at www.kaisernetwork.org/healthcast/kff/26jul05 . TOPICSMedicaidMedicare savings programsFederal health plansMedicareSocial SecurityDisabledChildren's healthChildren's Health Insurance Program Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 5 June 2018 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF download

Covering More Uninsured Doable–But Expensive

Back to table of contents Previous article Next article Government NewsFull AccessCovering More Uninsured Doable–But ExpensiveKate MulliganKate MulliganSearch for more papers by this authorPublished Online:15 Oct 2004https://doi.org/10.1176/pn.39.20.0390006There is good news and bad news about states' efforts to expand the number of people who are insured, Barbara Yondorf, president of a Denver-based health policy consulting firm, told an audience at the National Academy for State Health Policy's annual conference.“The good news is that there are strategies that work,” she said. “The bad news is that they are mostly expensive. Solutions will not be budget neutral.”Yondorf, who has headed the health and finance sections of the National Conference of State Legislatures (NCSL), wrote a paper titled “State Options for Expanding Health Care Access” for that organization in which she examined published literature about the results of states' efforts to expand coverage.Yondorf divided 26 options into three categories: expand private health insurance coverage, expand government-sponsored coverage programs, and expand direct care programs.She cautioned that the research had been conducted prior and up to the middle of 2003, so results did not reflect the impact of worsening state budget problems.Expansion of eligibility for Medicaid and the State Children's Health Insurance Program (SCHIP) are the “most effective” strategies for increasing coverage, Yondorf said. She quoted a statement from Leighton Ku, a senior fellow at the Center on Budget and Policy Priorities. “If enrollment in Medicaid and SCHIP had not grown in 2002, the number of Americans without health insurance would have been much higher [than 43.6 million].”Researchers for several studies have found that states can increase enrollment rates in Medicaid and SCHIP by intensifying outreach efforts and simplifying enrollment procedures.A SCHIP program in which the federal government provided premium assistance to employers who, in turn, insured low-income children of their employees has not been “particularly effective” because of its administrative complexity and cost.Enrollment in SCHIP declined in the second half of 2003 for the first time since the program was established in 1997 (Psychiatric News, September 3).An effort to encourage “Ticket to Work” participants to enroll in employer-sponsored health insurance and use Medicaid as a supplement has not been successful because the participants often work fewer hours than necessary to qualify for coverage. Ticket to Work waives some Medicaid income-eligibility requirements to encourage beneficiaries to obtain employment.The establishment by a state of a high-risk pool to cover otherwise uninsurable individuals has had a “small positive effect” on coverage rates. Enrollment in high-risk pools increased 20 percent between 2001 and 2002. In June 2002, however, those pools covered only 153,351 individuals, a figure that represents about .4 percent of the 41 million Americans without insurance.Pennsylvania, Washington, and Massachusetts have set up state-funded programs targeted to low-income individuals who are not eligible for Medicaid. In Washington, for example, the state offers premium subsidies for coverage from private insurance plans to people with incomes at 200 percent or less of the federal poverty level.Yondorf told the audience, “There were some surprising results. Some `obvious' strategies don't work.”Among them are the use of group purchasing mechanisms by small employers. A study of small-group purchasing alliances in California, Connecticut, and Florida found they “neither reduced small employer premiums nor increased the number of small businesses offering health insurance to their employees.”There is also no evidence that coverage is increased by the availability of state tax credits to small employers to offset their costs of providing insurance.Yondorf speculated that the size of the credit generally does not provide a sufficient incentive to employers.She offered concluding observations to the audience. “Convenience matters. It is one reason Medicaid expansion has been so successful. Build on existing programs and watch administrative costs.”And, finally, “Don't let ideology get in the way of evidence.”Copies of “State Options for Expanding Health Care Access” can be purchased for $30 at<http://ncsl.org/public/catalog/pubs.cfm?prodid=0166760006>.▪ ISSUES NewArchived

Ethnic politics, policy fragmentation, and dependent health care access in California.

One out of every six nonelderly Americans without health insurance lives in California. The problem of access to competent and dependable health care is especially problematic among the state's minority, and especially Hispanic, population. Because one-third of the country's Hispanics live in California, how this state deals with health access issues will affect the practice and progress toward universal care in the nation as a whole. Expanding health care access to California's dependent population will involve overcoming a number of well-known administrative and fiscal obstacles, including an underfunded, highly fragmented public health care system that has developed incrementally and incoherently over decades. However, a key to understanding the problem of access to health care in California involves a story of how ethnic conflict and partisan politics often conspire to deny or discourage access for eligible women and children.

The changing profile of the urban uninsured: exploring implications of rise in the number of moderate-income uninsureds.

Access to care is a major problem in urban America that increasingly affects new segments of the population. Although the demographic profile of the uninsured has changed, recording large increases in numbers of moderate-income uninsured persons, it has not been accompanied by changes in health care safety net programs or increased availability of private insurance products tailored to these groups. Any such changes, however, need to be based on a good understanding of the similarities and differences between low-income and moderate-income uninsured. Based on a telephone survey of the uninsured in three northern New Jersey counties, this study presents a systematic comparison of low-income (below 150% of federal poverty level) and moderate-income (150% to 350% federal poverty level) uninsured on attitudes to health care, perceptions regarding access to care, health status, and health care utilization. We discuss the implications of this comparison for expanding health care access and design of safety net programs and institutions.

Prehospital emergency care in Abu Dhabi, United Arab Emirates

Once a harsh land with limited resources, the United Arab Emirates (UAE) has undergone considerable change over the 50 years after the discovery of vast natural gas and petroleum reserves. In addition to significant economic and societal changes, remarkable improvements have been made in the provision of health care services, including expanded health care infrastructure, human resource development, and decreased infectious disease morbidity and mortality. Emergency medicine (EM) and emergency medical services (EMS) within the country are currently limited, with the UAE best described as being in the “developing” phase of EM. Within the capital city, Abu Dhabi, the Ministry of Health, Civil Defense, and police provide the majority of EMS services. At the present time, there are no uniform medical control or treatment protocols, communications systems, systems management, training or education, or quality assurance policies. However, the recent advancements in health care, and a developing practice of and interest in EM, may lead to improved EMS and prehospital care.

PREHOSPITAL EMERGENCY CARE IN ABU DHABI, UNITED ARAB EMIRATES

Once a harsh land with limited resources, the United Arab Emirates (UAE) has undergone considerable change over the 50 years after the discovery of vast natural gas and petroleum reserves. In addition to significant economic and societal changes, remarkable improvements have been made in the provision of health care services, including expanded health care infrastructure, human resource development, and decreased infectious disease morbidity and mortality. Emergency medicine (EM) and emergency medical services (EMS) within the country are currently limited, with the UAE best described as being in the “developing” phase of EM. Within the capital city, Abu Dhabi, the Ministry of Health, Civil Defense, and police provide the majority of EMS services. At the present time, there are no uniform medical control or treatment protocols, communications systems, systems management, training or education, or quality assurance policies. However, the recent advancements in health care, and a developing practice of and interest in EM, may lead to improved EMS and prehospital care.

Low-Income Children's Participation in a Public Health Insurance Program in Georgia

To expand health care coverage to uninsured, low-income children, the Congress created the State Children's Health Insurance Program (SCHIP) in 1997. Given ample evidence that state Medicaid programs have failed to enroll many eligible children, experts questioned whether SCHIP could successfully enroll low-income children. Using Georgia state SCHIP data, we analyzed enrollment patterns and identified factors contributing to program enrollment. This study found that the children's enrollment is explained by perceived costs and benefits of joining the program as well as the underlying family structure, demographic factors, and health status. We discuss implications of these findings on the participation of low-income families in public sector programs.

Utilizing the Continuum of Care in Wound Management

Today's health care environment demands flexibility and creativity in the manner that we provide services. The management of skin problems and pressure ulcers provides health care providers with different challenges today. This article will explore the expanded health care continuum and how an individual who has acquired a pressure ulcer can utilize the different settings. Ultimately, the goals remain the same: to heal the skin and maintain intact skin.

Frequency and distribution pattern of distant metastases in breast cancer patients at the time of primary presentation.

For routine staging of patients with primary breast cancer, clinical practice guidelines of many medical societies recommend chest X-ray, liver ultrasound and bone scan. With respect to expanding health care costs and patients' psychological distress it has been supposed, that there might be a group of breast cancer patients, who do not need these imaging studies. Four hundred and eighty-eight consecutive patients with primary breast cancer who had primary surgery at our institution and complete work-up for distant metastases including chest X-ray, liver ultrasound, and bone scan were studied. We found distant metastases at the time of primary diagnosis in 19 patients (3.9%). Bone metastases were found in 2.7%, liver metastases in 1.0%, and pulmonary metastases in 0.4%. However, in breast tumors smaller than 1 cm, no metastatic lesions were found, whereas 18.2% of the patients with pT4 tumors had metastases. In 2.4% of screening imaging studies, metastases were ruled out by additional imaging. Based on our data and a review of the literature, we suggest that chest X-ray, liver ultrasound and bone scan can be omitted in the staging of asymptomatic patients with pT1a or pT1b disease.

Cutting-edge discussions of management, policy, and program issues in emergency care

Effective staffing levels have become a topic of concern as a result of evidence that they are linked to quality patient outcomes, the expanding health care worker shortage, and the general public's awareness of patient safety issues. JCAHO defines staffing effectiveness as the number, competency, and skill mix of staff as related to the provision of needed services. It has a matrix approach (versus a single indicator) of both human resource (administrative) and clinical (service) indicators. The analysis of these indicators must be done at the level most effective for planning staffing needs within the organization (eg, for the department versus just one shift).

The case for diversity in the health care workforce.

Increasing the racial and ethnic diversity of the health care workforce is essential for the adequate provision of culturally competent care to our nation's burgeoning minority communities. A diverse health care workforce will help to expand health care access for the underserved, foster research in neglected areas of societal need, and enrich the pool of managers and policymakers to meet the needs of a diverse populace. The long-term solution to achieving adequate diversity in the health professions depends upon fundamental reforms of our country's precollege education system. Until these reforms occur, affirmative action tools in health professions schools are critical to achieving a diverse health care workforce.

Health insurance expansion through states in a pluralistic system.

The United States continues to stand almost alone among developed nations in its lack of universal health care coverage. In this essay, we argue that even though the debate over whether the federal government or states should lead the effort to expand health care coverage under the federal system is relevant in strategizing how to cover the uninsured; the more critical issues stem from the challenge of the mixed and fragmented mode of public-private financing of our pluralistic health care system. We base this argument on (1) an in-depth review of Oregon's and Tennessee's five years of experience with broad coverage reform in the context of the United States health care system and on (2) a more abbreviated review of other state experiences in providing health care coverage. We conclude from our review that when the will exists, states can substantially expand coverage. However, as one moves up the income scale, political support and resources are harder to come by. Further, concerns grow about the interface of public and private coverage, with issues of "crowd out" and other distributional questions dominating the discussion of coverage expansion as policy makers focus less on how to cover people than on how to make sure one kind of coverage doesn't preempt another. Concern for crowd out can then lead to policies that keep out some of the very people policy makers may want to cover. In this context the question whether states or the federal government is more likely to succeed in expanding coverage is eclipsed by the more fundamental challenges raised by pluralism. Neither federal nor state government is likely to be fully successful without first identifying ways of better coordinating public and private activities and resources to provide continuous and affordable coverage.

Universal coverage in the United States: lessons from experience of the 20th century.

Both the rising numbers of uninsured Americans and the recent presidential election have put the issue of universal health insurance coverage back on the national agenda. Lack of health insurance is a major barrier to care for 44 million Americans, and lack of high-quality, comprehensive insurance is a barrier to millions more. Universal coverage is one of the best ways to ensure that all Americans have equitable access to quality care, and it also contributes to the financial stability of health care providers, especially those in the urban safety net. A wide variety of ideas to expand health care coverage were proposed, and in some cases enacted, during the last century. At the beginning of the 21st century, the American health care system is made up of varied elements, ranging from employer-sponsored health insurance for the majority of working-age adults to the public Medicare program for the elderly. While this patchwork system leaves many Americans without health insurance, it also creates many different ways to expand coverage, including various options in both the private and public sectors. By understanding how the current health care system developed, how the various proposals for universal health coverage gained and lost political and public support, and the pros and cons of the various alternatives available to expand coverage, we create a solid base from which to solve the problem of the uninsured in the 21st century.

CONFIDENTIALITY IN THE EMERGENCY DEPARTMENT

The ideal of patient confidentiality has mutated over the last several years to accommodate the factors that infringe upon its meaning; such as expanding health care information technologies, physical environments that promote breaches of patient privacy, and health care workers who are unaware of how their routine behavior infringes on patients' right to privacy. This article examines the various ways in which confidentiality is breached in the emergency department and the legal issues involved, and explores options for the improvement of patient privacy for physicians and other health care professionals.