Expand Health Insurance Coverage Research Articles

Health Care Cost Containment and Coverage Expansion

Proposals to expand health insurance coverage are almost always accompanied by proposals to control the growth in health spending. Some people say that universal coverage cannot be achieved without cost containment, others that real cost savings will not be feasible without universal coverage. These arguments will be considered further below. Whether or not coverage expansion and cost controls are truly inseparable, it is likely that how the society goes about covering the uninsured may have implications for the feasibility of different possible approaches for controlling costs, and vice versa.People who favor a particular approach to covering the uninsured may also tend to favor certain cost containment approaches. For example, people who believe that consumers would be more cost-conscious if they were enrolled in high-deductible health plans are also likely to believe that coverage expansion should take the form of tax subsidies for the purchase of health insurance in a largely unregulated individual market. However, it is possible to conceive of a single-payer plan whose benefit package included a high initial deductible. The two pieces are not inherently contradictory or even ideologically inconsistent, particularly if the deductible were progressively income-based. (France actually has a single-payer system with income-based coinsurance.) It just happens that, in the current political environment, the intersection between consumer-directed health care advocates and single-payer advocates is practically a null set.This paper treats coverage expansion approaches and cost containment approaches as two distinct columns in the menu of health reform options: any choice from column A could theoretically be combined with any choice from column B. In practice, some combinations may work together better than others, and the interplay of different approaches to coverage and savings is the focus of this paper. There will be no attempt here to diagnose the sources of rapid health spending growth or to evaluate the likelihood that different proposed solutions can actually slow that growth. There is no shortage of analyses addressing these questions. Instead, the assumption is that every solution may offer at least some promise of savings-whether small or large, one-time or continuous. The question is what kind of insurance arrangements may make a preferred solution more or less workable.The paper begins with a brief review of the question posed at the outset: whether coverage expansion and cost controls must go hand-in-hand. It then lays out the menus of commonly proposed coverage approaches and available savings measures before considering how the two might go together. Because the number of possible combinations is quite large, the discussion will focus on just a few of the savings measures that have received the greatest attention from policymakers. In addition, this paper will not address measures intended to reduce the administrative costs of health insurance, as opposed to direct medical expenditures. Options for administrative simplification and their cost implications for insurers and providers are the subject of a separate paper for this project (Merlis 2008). It should be noted, however, that evaluating different coverage expansion approaches may require balancing their potential for medical spending restraint against their likely impact on administrative costs.

Paying a Fair Share for Health Coverage and Care

Questions about paying for health insurance and for health care can direct discussions down many paths. The ultimate goal is to structure contributions in a manner that ensures access to necessary and appropriate care and is also sustainable for individuals, families, insurers, other payers, and government. Choices about when and how much individuals and families should pay shape decisions about how those payments need to be structured. Comprehensive expansion of health coverage in the United States will mean augmenting, reorganizing, or creating new systems to administer payments for health coverage. The ability of administrative systems to implement reforms effectively needs to be factored into evaluating coverage expansions. Deciding how to structure payments will, however, also involve broader considerations of resources, incentives, and values. This paper provides a framework for considering the implications of different ways that people can pay for health coverage and care, drawing on research evidence as well as illustrations from existing private and public sector programs and the health care systems of other industrialized nations. The focus here is on two broad categories of health care costs borne by individuals and families. The first is paying for coverage, generally through premiums or taxes. The second is cost sharing for health services or supplies, generally consisting of deductibles, fixed copayments, or coinsurance (calculated as a fixed percentage of cost), often with limits on total annual out-of-pocket costs capped at a specific level, or different levels for different types of health care. Each category of costs can be structured in different ways, varying in amount covered, scope of benefits affected, special protections for vulnerable populations, and other design features. The number of permutations possible when different cost requirement are combined in insurance plans is practically infinite.

Designing Administrative Organizations for Health Reform

Many proposals for expanding health coverage involve the creation of organizations to produce information on comparative effectiveness, make coverage decisions, manage the marketplace for health insurance, or offer a public health insurance plan. These new organizations might take the form of a federal executive branch agency, an independent commission, government corporation, legislative branch agency, or public-private entity. Some proposals would create entities with substantial independence from the usual political processes, such as the Federal Reserve enjoys.The choice of an appropriate organizational structure to carry out a public function raises several issues: the source and predictability of the entity's funding, its operational flexibilities, its degree of political independence and accountability, and the structure of its management. These matters are not fully determined by an agency's organizational form, however, and targeted solutions are often available and usually preferable. For example, the Congress may provide an agency with a permanent appropriation or exemption from certain legal or regulatory constraints without removing it from an executive department.Organizations that use governmental powers and funds and make public policy need to be accountable as well as effective. A quasi-governmental or Federal Reserve-like entity might be suitable for producing advisory information on the comparative effectiveness of medical treatments but not for making decisions that directly affect the health coverage of individual Americans.

'Long Time Coming': Are We on the Brink of Universal Health Care Coverage?

The financial meltdown and bailout of September-October 2008 have shocked everyone. The headlines tell it all: Wall Street, R. I. P. (Creswell & White, 2008), Retirement accounts have lost $2 trillion so (J. H. Davis, 2008), Greenspan's free-market faith shaken (Irwin & Paley, 2008). Bernstein (2008), a well-known investment adviser and historian, described the bailout as an earth-shaking blow to the most basic principle of our economic namely, faith in individual decision-making in free markets (p. 8). Despite the severity of this crisis, we should not allow it to deflect attention from the ongoing meltdown of our health care system (http://medicine.plosjournals.org/perlserv/?request=getdocument &doi=10.1371/journal.pmed.0050208). In recent months, several studies and reports have examined the dimensions of this crisis: * The Commonwealth Fund Commission on a High Performance gave the U.S. health care system a score of 65 out of 100 on 37 core indicators of performance (http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=692682). * In 2007, 45 million people were without health insurance. Although this represented a decline from 2006, when 46.5 million people had no coverage, the improvement was due to an increase in through public programs (Fronstin, 2008). The uninsured population is likely to increase in 2008. * Twenty-five million people have inadequate coverage, which ensures neither access to care nor financial protection (K. Davis, 2008). Low-income people have particular difficulty finding adequate coverage. * Medical debt has become a serious problem, with a third of the population reporting their families have had difficulty paying medical bills (http://www.kff.org/newsroom/ posr102108nr.cfm). One study suggests that health care issues, including sickness and medical debt, may play a central role in home foreclosures (http://works.bepress.com/cgi/ viewcontent.cgi?article=1001&context= christopher_robertson). * Between 1999 and 2007, while health insurance premiums grew by 114 percent, earnings grew by just 27 percent (http://www.rwjf. org/pr/product.jsp?id=35368). * Women buying in the nongroup health insurance market often pay far more than men do for identical coverage (Pear, 2008). These grim realities are not new to social workers or readers of Health & Social Work. What is new is their context. Whatever we may think of the bailout, it has undermined two central ideological objections to universal health care (UHC).The first is that we need to limit the role of government. It is difficult to oppose an expanded role for government when perhaps the most conservative administration since the 1920s not only partially nationalized our banking system, but also gave bankers no choice in the matter. In addition, the Bush administration is developing a plan to assist homeowners facing foreclosure (Bajaj, 2008). If we can take radical steps like these, why not regulate our health care system and extend to people without insurance? The second objection is that government provision of health care promotes what economists call moral hazard (Nyman, 2004). Moral hazard occurs when insurance insulates or protects individuals from the consequences of their actions (Gladwell, 2005). In terms of health care, if individuals know that the government or an insurance company will pay their bills, they will be more willing to engage in reckless behavior than they would if the burden of cost fell to them. Nyman (cited in Gladwell, 2005) argued that concern about moral hazard explains 'the general lack of enthusiasm by U.S. health economists for the expansion of health insurance coverage.' However, the financial bailout has made a mockery of concern about moral hazard. Once the federal government declares, 'Thou shalt not fail,' there are no limits to how far future risk-takers will go (Bernstein, 2008, p. …

U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey

BACKGROUNDPhysician opinion can influence the prospects for health care reform, yet there are few recent data on physician views on reform proposals or access to medical care in the United States.OBJECTIVETo assess physician views on financing options for expanding health care coverage and on access to health care.DESIGN AND PARTICIPANTSNationally representative mail survey conducted between March 2007 and October 2007 of U.S. physicians engaged in direct patient care.MEASUREMENTSRated support for reform options including financial incentives to induce individuals to purchase health insurance and single-payer national health insurance; rated views of several dimensions of access to care.MAIN RESULTS1,675 of 3,300 physicians responded (50.8%). Only 9% of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42% preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance.CONCLUSIONSThe vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.

Putting The Public's Money Where Its Mouth Is

This paper reports the results of a 2009 national survey that quantifies Americans' willingness to pay to expand health insurance coverage. We asked respondents whether they would support a Medicaid expansion, a subsidy for low-income people, or a subsidy for the chronically ill, if they had to pay more income taxes to cover the program's costs. Based on respondents' reported income, we told them approximately how much, in dollar terms, their tax increases would be. Our results reflect a tension in public opinion recognized by previous investigators: a desire for reform but limited willingness to pay for it.

The Long And Winding Road: Reflections On California's ‘Year Of Health Reform’

California's recent failed attempt to expand health coverage broadly offers lessons for future coverage expansion efforts. Policy efforts are most likely to advance if they are bipartisan; address the needs of both insured and uninsured residents; deliver short-term progress within the context of long-term goals; rely on broad and sustainable financing; strike a balance between specificity and flexibility; and occur within a clearer framework of state and federal responsibilities.

Primary Care Delivery Changes as Nonphysician Clinicians Gain Independence

Current Clinical Issues21 October 2008Primary Care Delivery Changes as Nonphysician Clinicians Gain IndependenceJennifer Fisher WilsonJennifer Fisher WilsonSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-149-8-200810210-00025 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail States across the United States have expanded health insurance coverage to more of their uninsured residents, resulting in at least 1 million more people having health insurance in 2007 than in 2006. These state-level health reforms should result in improved health care for a greater portion of the population. But the shortage of physicians, at least in some areas, has raised questions about whether the increased demand for care can be met. One study found that about 56 million U.S. residents do not have a regular source of health care because of physician shortages in their areas (1). Some patients ...

A predictive model for the utilization of curative ambulatory health services in Mexico

To estimate the degree to which individual and household variables jointly predict utilization of curative ambulatory services in Mexico for four types of health providers. Patient choice of provider (self-care, Ministry of Health, social security, or private provider) when they become ill is modeled using a nested multinomial logit model that uses household and individual variables as predictors. The data are from the Mexican National Health Survey conducted in 2000. Being a social security beneficiary is one of the most important predictors of utilization. A strong positive relationship between socio-economic status (SES) and demand for services was also found, with the strongest relationship being for private providers, followed by social security. Utilization of Ministry of Health (MoH) services was negatively associated with household SES. Expansion of health insurance coverage should significantly reduce health inequalities due to reduced care-seeking by non-beneficiaries.

Authors’ Response

To the Editor: We read with interest the letter from Dr. Nachman Brautbar regarding our article1 “The Association of Diabetes with Job Absenteeism Costs among Obese and Morbidly Obese Workers” published in this journal in May 2008. Dr. Brautbar asks how employers can facilitate employee weight management and who would bear the cost. We thank Dr. Brautbar for his interest and we are happy to provide the requested information. There are a variety of ways that employers can promote healthy weight among their employees. First, employers can engage in workplace health promotion programs. The Task Force on Community Preventive Services recommends use of worksite interventions that combine nutrition and physical activity to help employees lose weight.2 Some recent innovative programs involve employers offering financial incentives for employees to lose weight and maintain their weight loss.3 Second, employers can expand their health insurance coverage to include bariatric surgery, antiobesity drugs, and dietary counseling. Our research indicates that job absenteeism is highest among morbidly obese diabetics, implying that weight reductions in this group may benefit employers the most. This suggests that health insurance coverage of bariatric surgery is particularly relevant. A recent literature review singled out obesity surgery as the most effective treatment for achieving significant and sustainable weight loss,4 and it is considerably more successful than conventional medical and behavioral therapy in resolving diabetes among the obese population.5 The costs of weight loss treatments programs vary with the type of intervention chosen and with the targeting of the intervention. The cost-effectiveness of some antiobesity interventions has been documented but many more interventions remain to be assessed.6 With regard to who pays for expanded health insurance coverage, evidence from the labor and health economics literatures indicates that employees ultimately pay for it in the form of lower wages; in a recent survey 91% of health economists agreed that “workers pay for employer-sponsored health insurance in the form of lower wages or reduced benefits.”7 Thus, in the end employees bear any increase in health insurance premia that results from covering these treatments. Challenges remain to implementing such programs. For example, the costs of these programs must be paid up-front while some of the benefits occur in the distant future. Due to employee turnover, employers do not reap the full benefits of such programs, creating a disincentive for their implementation. Likewise, insurance companies do not reap all of the savings that result from preventive care because of turnover of their insurance pool. Finding ways to eliminate such disincentives is an important area for future research. John Cawley, PhD Department of Policy Analysis and Management Cornell University Ithaca, NY John A. Rizzo, PhD Department of Economics and Department of Preventive Medicine Stony Brook University Stony Brook, NY Kara Haas Ethicon Endo-Surgery, Inc. Cincinnati, OH

The Role of Citizenship, Employment, and Socioeconomic Characteristics in Health Insurance Coverage Among Asian Subgroups in the United States

Asians are the third largest and one of the fastest growing minority groups in the United States. We present health insurance data for the 6 largest national subgroups: Chinese, Filipino, Indian, Korean, Vietnamese, and Japanese. We also contrast the characteristics that result in differences in coverage, including the role of citizenship. Cross-sectional analysis of data from the 2006 Current Population Survey. We used responses to questions on nativity and parental nativity to categorize Asian respondents into subgroups. The 2006 CPS sampled 8918 Asians including 1923 Chinese, 2210 Filipino, 1302 Indian, 951 Korean, 903 Vietnamese, and 808 Japanese. Koreans had the highest proportion lacking coverage at 29.8%, followed by Vietnamese at 21.5% and Chinese at 16.8%. Indians, Filipinos, and Japanese had rates of coverage similar to or better than non-Hispanics whites (NHWs). The proportion of US-born Chinese with employer coverage (65%) was similar to NHWs, but only 50% of Chinese noncitizens had employer coverage and 27% of these were uninsured. Among Koreans and Vietnamese, noncitizens were most vulnerable, with 41% and 31%, respectively, being uninsured. In contrast, 70% of noncitizen Indian had employer coverage and only 15% were uninsured. Gaps in coverage among Koreans and Vietnamese were largely due to employment in service industry and blue collar occupations as well as small firms, which are less likely to provide coverage. The current system of employer coverage is not succeeding in covering Asian groups equitably. Distinct initiatives to expand health coverage would have variable effects on these diverse subgroups.

Loss of Health Insurance Among Non-elderly Adults in Medicaid

Major policy efforts to expand health coverage to the uninsured are under consideration. Drop-out among children in Medicaid--due to annual renewal requirements--is well-documented, but the recent extent of this problem among non-elderly adults is unknown. To estimate the loss of health insurance over time among adults in Medicaid and identify risk factors for drop-out. Survival analysis of Medicaid enrollment, using Kaplan-Meier curves and Cox proportional-hazards regression. Data are from the nationally representative Medical Expenditure Panel Survey, 2000-2004. The sample consists of non-elderly adults (n = 4,992) and children (n = 8,559) in Medicaid. Insurance status after 12 months was measured for all individuals enrolled in Medicaid at the survey's outset. A survival analysis of disenrollment was then conducted for newly enrolled individuals. Nationwide, 2 million adults leave Medicaid and become uninsured annually. Disenrollment was significantly higher among adults than children (hazard ratio 1.75, 95% CI 1.65-1.86). Respectively, 20%, 43%, and 55% of adults disenrolled within 6, 12, and 23 months of initial enrollment. Lost eligibility explained a small portion of disenrollment. Six months after disenrolling, 17% had reenrolled in Medicaid, 34% had other insurance, and 49% were uninsured. Men, younger adults, and Hispanics were more likely to drop out; those in Medicaid managed care or with disabilities were less likely. Overall health status and diseases, such as diabetes, heart disease, and depression, had no effect on drop-out. Drop-out from Medicaid is a major problem among adults--even among those with chronic diseases--and contributes to the presence of millions of uninsured Americans. Policy efforts to expand health coverage must address poor Medicaid retention. Clinicians should be aware of this issue when caring for non-elderly adults in Medicaid.

Cost-Reducing Innovation In Health Care

Ever-increasing health care costs undermine expansions in health insurance coverage. Debate about lowering unit costs tends to focus on reducing payment levels for existing products and providers, but such measures are not likely to succeed, given established overhead costs and income expectations. Instead, moderation in health care spending must be sought in new products and processes that use lower-cost materials, staff, equipment, and sites of care. We give examples and sketch the principal regulatory, payment, insurance, and policy design obstacles to the further development and diffusion of cost-reducing innovations.

Lessons From The Field: Expanding Health Insurance Coverage One County At A Time

From 2004 to 2007 the California HealthCare Foundation's Step by Step: Local Coverage Expansion initiative supported insurance coverage expansions for uninsured children and adults in thirty California counties. In this paper we descbribe the initiative and its achievements as well as challenges for grantees. Also, we discuss the implications of the initiative's outcomes for expanding coverage locally and more broadly. Implementing new insurance programs is possible in the most difficult settings. Although there are real challenges to sustaining these expansions and limits to what they can accomplish in the face of major unmet needs, they may lay useful groundwork for broader expansions later.

Collaboration and competition in a children's health initiative coalition: A network analysis

Activating communities to achieve public health change and initiate policy reform usually requires collective action from many entities. This case study analyzes inter-organizational networks among members of a coalition created to expand health insurance coverage to uninsured children in a large metropolitan area. Six networks were measured: collaboration, competition, formal agreements, receive funding from, send funding to, and greater communication. The response rate was 65.8% (50 of the 76 active members). Positive network questions such as “who do you collaborate with” elicited many network choices whereas negative ones such as “who do you compete with” elicited few. The collaboration network had a core–periphery structure and analysis showed that a large network can be reduced to a small set of core organizations one-sixth the size of the whole. Centrality (out- and in-degree) was associated with perceived organizational function and perceived barriers to success. For example, organizations that received many choices as collaboration partners were more likely to perceive the coalition functioned well than those who received few choices. The study suggests that perceptions of organizational performance are associated with position in the network, central members are more likely to perceive the organization performs well than those on the periphery.

The Influence of Health Insurance on Parent’s Reports of Children’s Unmet Mental Health Needs

The purpose of this study was to examine the prevalence of unmet mental health needs in children identified by parents as having long-term emotional and behavioral problems, to identify the characteristics of these children, and to evaluate the influence of health insurance status and type on the odds of reporting unmet mental health needs. We used the National Survey of Children with Special Health Care Needs (NSCSHCN) to estimate the prevalence of unmet mental health needs among children with long-term emotional/behavioral conditions. Using logistic regression models, we also assessed the independent impact of insurance status and type on unmet needs. Analyses indicated that of the nearly 67% of children who needed mental health care or counseling in the previous 12 months, 20% did not receive it. Moreover, parents of uninsured children were more likely to report unmet mental health needs than insured children. Parents of children covered by public health insurance programs (Medicaid, Children Health Insurance Program-CHIP, Title V, Military, Native American) were less likely to report unmet mental health needs than those with children covered by private health insurance plans. Results from this study suggest a need for expansion of health insurance coverage to children especially those with long-term mental health conditions. It also suggests a need for parity between mental and physical health benefits in private health insurance.

A Federalist Approach To Health Reform: The Worst Way, Except For All The Others

Support for state action should be part of any strategy to expand health insurance coverage. Decades-long political deadlock in Washington has frustrated national efforts to expand coverage. Some states have already undertaken to do this; others show a determination to do so. Regulatory and legislative flexibility would trigger widespread state action. Whether one thinks that ensuring coverage requires a unified national approach or that diverse conditions require different methods in different states, the likelihood of progress will be advanced if states test out various ways to expand coverage. We describe a practical way by which the federal government can promote state action to expand health insurance coverage.

FRANKS ET AL. RESPOND

Farrelly and Engelen appear to have repeated our analyses, but have included 2 more recent years of data and used Nielsen retail price data as well as the tax burden data that we used. There are some noteworthy inconsistencies. First, despite using more years of data, their sample size was over 1 million persons smaller than ours. Second, they noted that a meta-analysis found an elasticity of −0.4, which is what we found in the earlier time period. However, the elasticity they reported throughout was much lower (range: −0.1 to −0.13). This lower elasticity is actually less than the elasticity we reported (−0.14) for poorer persons in the more recent time period. Third, despite the smaller sample size and lower elasticity, they reported the effect as statistically significant, whereas we found a larger effect not statistically significant. Fourth, the rationale for using Neilson data is that actual prices may be lower than those in the tax burden data. Thus, use of the tax burden data may underestimate elasticity. However, paradoxically, their results using Nielsen data compared with the tax burden data suggest less elasticity with the Nielsen data. The reasons for these inconsistencies are unclear, given the limited presentation of their methods. One possibility is that they ignored the clustered nature of the data (thereby overstating the statistical significance of their findings); another is that the Nielsen data are problematic.1 Beyond these methodological issues, there are some important policy implications of our findings. While higher prices may still contribute to smoking cessation (and reduced initiation), the gap between the poor and less poor in smoking is increasing. The burden of higher cigarette prices thus falls increasingly on poorer persons. Funding broad social policies (like expansion of health care coverage) through taxation aimed at a narrow, poor segment of society may be politically expedient. However, in our view, such policy is short sighted and contributes to the fragmentation of social cohesiveness. Further, if higher prices do lead to reduced smoking, then tax revenues will decline, undermining the fiscal basis of the expanded health coverage.

Public And Private Health Insurance: Stacking Up The Costs

Some proposals to expand health insurance coverage for people with low incomes are based on expansions of public programs, such as Medicaid or the State Children's Health Insurance Program (SCHIP), while others rely on the use of tax subsidies for individuals to purchase private insurance. Analyses of data from the 2005 Medical Expenditure Panel Survey indicate that total medical spending is much lower when coverage is provided by Medicaid or SCHIP than it is when coverage is provided by private insurance. Public insurance is particularly advantageous from the consumer's perspective because associated out-of-pocket spending is far lower.

Assessing horizontal equity in medication treatment among elderly Mexicans: which socioeconomic determinants matter most?

Many low- and middle-income countries are currently undergoing a dramatic epidemiological transition, with an increasing disease burden due to degenerative noncommunicable diseases. Inexpensive medication treatment often represents a cost-effective means to prevent, control or cure many of these health conditions. Using micro-data from the 2001 Mexican Health and Aging Study, we assess horizontal inequity in medication treatment among older Mexicans before the introduction of Popular Health Insurance in Mexico. In doing so, we investigate the role of various dimensions of socioeconomic status for obtaining indicated medication treatment within a comparatively fragmented health-care system that features relatively high out-of-pocket expenditures. Our empirical analysis suggests health insurance coverage as a key socioeconomic determinant of indicated medication use with large and statistically significant positive effects on take-up. The effects of insurance status thereby clearly dominate any other possible effects of socioeconomic status on medication treatment. Our results thus highlight the importance of access to reliable health care and comprehensive coverage for rational medication use in the management of degenerative diseases. In light of this evidence, we expect that recent Mexican health-care reforms, which expand health insurance coverage to the previously uninsured population, will alleviate socioeconomic gradients in medication treatment among older people in need.