Health Insurance Coverage Rates Research Articles

The Effects of the Dependent Health Insurance Coverage Mandates on Fathers’ Job Mobility and Compensation

Due to the low rates of health insurance coverage among young adults, some state governments began mandating health insurance companies to allow adult children to stay on their parents’ health insurance plans. First implemented in 1995, these mandates aimed to increase insurance coverage among young adults. In 2010, the federal government enacted a more comprehensive version of the dependent coverage mandate as part of the Affordable Care Act. These state- and federal-level efforts increased insurance rates for young adults, but they might have also come with unintended consequences for parents. Parents who placed a high value on health insurance for their young adult children might be reluctant to leave jobs with employer-provided health insurance, and employers might offset the mandate-incurred health care costs by reducing other types of employee benefits or earnings. To assess the extent of such consequences, I study the effects of both the state- and federal-dependent health insurance mandates on fathers’ voluntary job separation rates (job-lock and job-push) and changes in their compensation. I observe a significant decrease in the likelihood of voluntary job separation among eligible working fathers aged 45–64 and find weak evidence that the mandates reduced certain fathers’ total monetary compensation.

Labor-Market Concentration and Labor Compensation

This paper estimates the effect of labor-market concentration on labor compensation across the U.S. private sector since 2000. We distinguish between concentration in local labor markets versus local product markets, guarding against bias from confounded product-market concentration. Analysis extends beyond wages to rates of employment-based health insurance coverage. Estimates suggest negative effects of labor-market concentration on labor compensation. This comes through both reducing the human-capital level of those in the market and reducing pay conditional on human-capital level. Higher product-market concentration exacerbates and higher unionization rates mitigates these effects.

A Cluster-Based Machine Learning Ensemble Approach for Geospatial Data: Estimation of Health Insurance Status in Missouri

Mainstream machine learning approaches to predictive analytics consistently prove their ability to perform well using a variety of datasets, although the task of identifying an optimally-performing machine learning approach for any given dataset becomes much less intuitive. Methods such as ensemble and transformation modeling have been developed to improve upon individual base learners and datasets with large degrees of variance. Despite the increased generalizability and flexibility of ensemble approaches, the cost often involves sacrificing inference for predictive ability. This paper introduces an alternative approach to ensemble modeling, combining the predictive ability of an ensemble framework with localized model construction through the incorporation of cluster analysis as a pre-processing technique. The workflow not only outperforms independent base learners and comparative ensemble methods, but also preserves local inferential capability by manipulating cluster parameters and maintaining interpretable relative importance values and non-transformed coefficients for the overall consideration of variable importance. This paper demonstrates the ensemble technique on a dataset to estimate rates of health insurance coverage across the state of Missouri, where the cluster pre-processing assists in understanding both local and global variable importance and interactions when predicting high concentration areas of low health insurance coverage based on demographic, socioeconomic, and geospatial variables.

Health insurance coverage and health care utilization: Evidence from the Affordable Care Act's dependent coverage mandate.

This paper investigates the impact of the Affordable Care Act's (ACA's) dependent coverage mandate on health insurance coverage rates and health care utilization among young adults. Using data from the Medical Panel Expenditure Survey, I exploit the discontinuity in health insurance coverage rates at age 26, the new dependent coverage age cutoff enforced by the ACA. Under alternative regression discontinuity design models, I find that 2.5 to 5.3 percent of young adults lose their health insurance coverage once they turn 26. This effect is mainly driven by those who lose their private health insurance plan coverage and those who lose their health insurance plan coverage, whose main holder resides outside of the household. I also find that the discrete change in health insurance coverage rates at age 26 is associated with up to a 3.6 percentage point decrease in office-based physician and and up to a 2.1 percentage point decrease in dental visits, but does not have a significant impact on the utilization of outpatient or emergency department services. Furthermore, the effects of the ACA's dependent coverage mandate on health care spending and out-of-pocket costs are insignificant. These results are robust under alternative model specifications.

Ensemble machine learning prediction of posttraumatic stress disorder screening status after emergency room hospitalization

Posttraumatic stress disorder (PTSD) develops in a substantial minority of emergency room admits. Inexpensive and accurate person-level assessment of PTSD risk after trauma exposure is a critical precursor to large-scale deployment of early interventions that may reduce individual suffering and societal costs. Toward this aim, we applied ensemble machine learning to predict PTSD screening status three months after severe injury using cost-effective and minimally invasive data. Participants (N = 271) were recruited at a Level 1 Trauma Center where they provided variables routinely collected at the hospital, including pulse, injury severity, and demographics, as well as psychological variables, including self-reported current depression, psychiatric history, and social support. Participant zip codes were used to extract contextual variables including population total and density, average annual income, and health insurance coverage rates from publicly available U.S. Census data. Machine learning yielded good prediction of PTSD screening status 3 months post-hospitalization, AUC = 0.85 95% CI [0.83, 0.86], and significantly outperformed all benchmark comparison models in a cross-validation procedure designed to yield an unbiased estimate of performance. These results demonstrate that good prediction can be attained from variables that individually have relatively weak predictive value, pointing to the promise of ensemble machine learning approaches that do not rely on strong isolated risk factors.

The effect of health insurance reform: Evidence from China

This paper estimates the impact of a health insurance reform on health outcomes in urban China. Using the China Health and Nutrition Survey11This research uses data from China Health and Nutrition Survey (CHNS). We should thank the National Institute of Nutrition and Food Safety, China Center for Disease Control and Prevention, Carolina Population Centre, the University of North Carolina at Chapel Hill, the NIH (R01-HD30880, DK056350, and R01-HD38700) and the Fogarty International Centre, NIH for financial support for the CHNS data collection and analysis files from 1989 to 2006 and both parties plus the China-Japan Friendship Hospital, Ministry of Health for support for CHNS 2009 and future surveys. we find that this reform increases the rate of health insurance coverage significantly among workers in Non-State Owned Enterprises. The double difference (DD) estimations show that the reform also leads to better health outcomes: workers are less likely to get sick and more likely to use preventive care. Using an instrumental variable (IV) approach to look at the causal effect of health insurance, we find those with health insurance use more preventive care but do not report significantly better health outcomes, an increase in health care utilisation, or an increase in out-of-pocket medical expenditure.

Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act.

The Affordable Care Act (ACA) aims to expand health insurance coverage and minimize financial barriers to receiving health care services for individuals. However, little is known about how the ACA has impacted individuals with mental health conditions. This study finds that the implementation of the ACA is associated with an increase in rate of health insurance coverage among nonelderly adults with serious psychological distress (SPD) and a reduction in delaying and forgoing necessary care. The ACA also reduced the odds of an individual with SPD not being able to afford mental health care. Mental health care access among racial and ethnic minority populations and people with low income has improved during 2014-2016, but gaps remain.

Longitudinal Analysis of Racial/Ethnic Trends in Quality Outcomes in Community Health Centers, 2009-2014.

To monitor progress towards eliminating health disparities, community health centers have reported on hypertension control, diabetes control, and birthweight by race and ethnicity since 2008. To evaluate racial/ethnic time trends in quality outcomes in health centers and to assess both within- and between-center disparities in outcomes. Using 2009-2014 data from all US health centers (n=1047 centers, serving 19.6 million patients/year), we evaluated racial/ethnic time trends in quality outcomes for health centers and assessed within- and between-center disparities. Percentage of patients achieving control of blood pressure<140/90mmHg among hypertensive persons, control of glycosylated hemoglobin ≤ 9.0% among diabetic persons, and birthweight ≥2500g. All outcomes were reported by race/ethnicity. There was no evidence of improved outcomes among racial/ethnic subgroups from 2009 to 2014, though electronic health record adoption, medical recognition, and insurance coverage rates increased substantially. Two exceptions were increased rates of normal birthweight for black patients (87.0% to 88.8%, or 0.3 percentage points/year, p=0.02) and decreased rates of diabetes control for white patients (74.2% to 69.5%, or -1.0 percentage points/year, p<0.01). Within centers, the largest racial/ethnic disparities in 2009 were white/black disparities in hypertension control (8.7 percentage points, 95% CI 7.4-10.1), white/black disparities in diabetes control (3.4 percentage points, 95% CI 2.0-4.7), and white/Hispanic disparities in diabetes control (4.4 percentage points, 95% CI 2.8-6.0). All disparities remained statistically unchanged from 2009 to 2014. White patients were more likely to be seen at a health center in the top performance quintile compared with black and Hispanic patients (p<0.001). Though quality outcomes in health centers continued to compare favorably to other care settings, we found no evidence of improved quality or reduced disparities in diabetes control, hypertension control, or birthweight from 2009 to 2014. Within- and between-center racial/ethnic disparities in quality were evident, and both should be targeted in future interventions.

Prevalence of Self-Reported Chronic Diseases and Health Services Utilization by Ethnic Minorities in Manaus Metropolitan Region.

To assess the prevalence of, and associated factors to, self-reported chronic diseases and health care utilization by ethnicity in the Manaus Metropolitan Region. We conducted a cross-sectional, population-based survey from May through August 2015. Using probabilistic sampling in three stages, we recruited adults aged ≥18 years. Ethnicity was self-identified as White, Black, Yellow, Brown (Brazilian mixed-race), and Indigenous. We calculated adjusted prevalence ratios (PR) and 95% CI of chronic diseases and health service utilization for each ethnic minority and compared the data using Poisson regression with data from White respondents. In this study, we interviewed 4,001 people. Of these, 15.9% were White, 7.5% Black, 3.4% Yellow, 72.1% Brown, and 1.0% Indigenous. Indigenous respondents had the highest prevalence of self-reported hypertension (29.4%), diabetes (12.3%) and hypercholesterolemia (17.0%) among the ethnic respondent groups. Compared with the White population, Browns had less health insurance coverage (PR=.76; 95% CI: .62-.93) and reported hypertension (PR=.84; 95% CI: .72-0.98) and diabetes (PR=.69; 95% CI: .51-.94) less frequently. Yellows visited the doctor more frequently than Whites (PR=1.13; 95% CI: 1.04-1.22), with no significant difference in prevalence of diseases. Indigenous respondents had higher prevalence rates of the investigated diseases. Compared with Whites, Brown respondents had lower rates of self-reported arterial hypertension and diabetes, as well as lower rates of private health insurance coverage.

The Effect of Health Insurance Reform: Evidence from China

This paper estimates the impact of a health insurance reform on health outcomes in urban China. Using the China Health and Nutrition Survey we find that this reform increases the rate of health insurance coverage significantly among workers in Non-State Owned Enterprises. The double difference (DD) estimations show that the reform also leads to better health outcomes: workers are less likely to get sick and more likely to use preventive care. Using an instrumental variable (IV) approach to look at the causal effect of health insurance, we find those with health insurance use more preventive care but do not report significantly better health outcomes, an increase in health care utilisation, or an increase in out-of-pocket medical expenditure.

Trends in Health Insurance Coverage of Title X Family Planning Program Clients, 2005-2015.

The federal Title X Family Planning Program supports the delivery of family planning services and related preventive care to 4 million individuals annually in the United States. The implementation of the 2010 Affordable Care Act's (ACA's) Medicaid expansion and provisions expanding access to health insurance, which took effect in January 2014, resulted in higher rates of health insurance coverage in the U.S. population; the ACA's impact on individuals served by the Title X program has not yet been evaluated. Using administrative data we examined changes in health insurance coverage among Title X clinic patients during 2005-2015. We found that the percentage of clients without health insurance decreased from 60% in 2005 to 48% in 2015, with the greatest annual decrease occurring between 2013 and 2014 (63% to 54%). Meanwhile, between 2005 and 2015, the percentage of clients with Medicaid or other public health insurance increased from 20% to 35% and the percentage of clients with private health insurance increased from 8% to 15%. Although clients attending Title X clinics remained uninsured at substantially higher rates compared with the national average, the increase in clients with health insurance coverage aligns with the implementation of ACA-related provisions to expand access to affordable health insurance.

The Association of Health Reform and Infant Health: Evidence from Massachusetts.

To estimate whether the incidence of low birthweight and rates of infant mortality were associated with Massachusetts health reform in the overall population and for subgroups that are at higher risk for poor health outcomes. Individual-level data on birthweight were obtained from the National Center for Health Statistics detailed natality files, and aggregated county-level mortality rates were generated from linked birth-death files. We used restricted versions of each file that had intact state and substate geographic identifiers. We employed a quasi-experimental difference-in-differences design. We found small and statistically nonsignificant associations between the reform and the incidence of low birthweight and infant mortality rates. Results were consistent across a number of subgroups and were robust to alternative comparison groups and alternative modeling assumptions. We found no evidence that the Massachusetts reform was associated with improvements in individual low birthweights or county-level infant mortality rates, despite increasing health insurance coverage rates for adult women of child-bearing age. Because our mortality analysis was ecological, we are not able to draw conclusions about how an individual-level health insurance intervention for uninsured pregnant women would affect the mortality outcomes of their infants.

Despite Boosting Children's Coverage Rates To Historic Levels, Medicaid And CHIP Face An Uncertain Future.

The Children's Health Insurance Program (CHIP), which was enacted twenty years ago, covers uninsured children who do not qualify for Medicaid but lack access to affordable coverage. Together these safety-net programs have boosted the health insurance coverage rate among US children to historic levels, exceeding 95percent of children in 2015. However, the future of both CHIP and Medicaid is uncertain. In the current congressional debate over the Affordable Care Act, Medicaid has become a target for potential funding reductions and other changes that would undermine the scope of children's coverage. Congress has yet to act to extend CHIP funding beyond September30, 2017, when the current appropriation expires. State and federal policy makers should act now to preserve the foundation of coverage currently in place while striving to ensure that every child in the United States has health coverage.

Health Insurance In China: After Declining In The 1990s, Coverage Rates Rebounded To Near-Universal Levels By 2011.

We analyzed trends in rates of health insurance coverage in China in the period 1991-2011 and the association of health insurance with hypertension and diabetes based on data from eight waves of the China Health and Nutrition Survey. The rate of coverage fell from 32.3percent in 1991 to 21.9percent in 2000, rebounding to 49.7percent in 2006 and then rapidly climbing to 94.7percent in 2011. Our study indicated that neither the prevalence of diabetes nor that of hypertension was significantly associated with health insurance coverage. When patients were aware of their condition or disease, those with insurance had a significantly higher likelihood of treatment for diabetes and hypertension, compared to those without insurance. We observed an association between health insurance coverage and seeking preventive care and receiving medical treatment when patients were aware of their condition or disease.

Health Insurance Coverage and Health Care Utilization: Evidence from the Affordable Care Act's Dependent Coverage Mandate

This paper investigates the impact of the Affordable Care Act’s (ACA’s) dependent coverage mandate on health insurance coverage rates and health care utilization among young adults. Using data from the Medical Panel Expenditure Survey, I exploit the discontinuity in health insurance coverage rates at age 26, the new dependent coverage age cutoff enforced by the ACA. Under alternative regression discontinuity design models, I find that 2.5% to 5.3% of young adults lose their health insurance coverage once they turn 26. This effect is mainly driven by those who lose their private health insurance plan coverage and those who lose their health insurance plan coverage, whose main holder resides outside of the household. I also find that the discrete change in health insurance coverage rates at age 26 is associated with significant changes in office-based physician and dental visits, but does not have a significant impact on the utilization of outpatient or emergency department services. Furthermore, the effects of the ACA’s dependent coverage mandate on health care spending and out-of-pocket costs are insignificant. These results are robust under alternative model specifications.

Men as Dependents? Marriage and Changes in Health Insurance Coverage among Working-age Adults in the United States, 1988 to 2008

Changes in marriage and employment patterns may have affected health insurance coverage rates differently for women and men. The author investigates changes in health insurance coverage between 1988 and 2008, focusing on employer-sponsored insurance (ESI) dependent and employee coverage. Using Oaxaca-Blinder decompositions and Current Population Survey data, the author finds that married men’s coverage as dependents increased from 1988 to 2008, but a smaller share of men were married in 2008. Coupled with declines in ESI employee coverage, changes in marriage increased men’s uninsurance rate. In contrast, marital changes for women were offset by their increased employment and insurance coverage as employees.

Psychological Distress and Rates of Health Insurance Coverage and Use and Affordability of Mental Health Services, 2013-2014.

The study compared changes in rates of health insurance coverage, utilization and affordability of mental health services, and reported satisfaction with health coverage between 2013 and 2014 for people in moderate and severe psychological distress with people in no or low psychological distress. A nationally representative data set restricted to participants ages 26 to 65 (N=35,602) was used. Changes in outcome measures were calculated by using linear regression adjusted for the complex survey design. Relative to individuals with no or low levels of psychological distress, individuals with moderate distress showed gains on selected outcome measures, and they experienced net improvements on several measures. Individuals with severe psychological distress showed fewer net improvements and no relative improvements compared with individuals with no or low levels of psychological distress, although they reported net increases in subjective satisfaction with health care. Between 2013 and 2014, selected health care outcomes improved for individuals in moderate psychological distress but not for individuals in severe distress.

A new role for primary care teams in the United States after "Obamacare:" Track and improve health insurance coverage rates.

Maintaining continuous health insurance coverage is important. With recent expansions in access to coverage in the United States after "Obamacare," primary care teams have a new role in helping to track and improve coverage rates and to provide outreach to patients. We describe efforts to longitudinally track health insurance rates using data from the electronic health record (EHR) of a primary care network and to use these data to support practice-based insurance outreach and assistance. Although we highlight a few examples from one network, we believe there is great potential for doing this type of work in a broad range of family medicine and community health clinics that provide continuity of care. By partnering with researchers through practice-based research networks and other similar collaboratives, primary care practices can greatly expand the use of EHR data and EHR-based tools targeting improvements in health insurance and quality health care.

Growing concerns and controversies to Taiwan's National Health Insurance—what are the lessons from mainland China, South Korea and Singapore?

It has been over 20 years since Taiwan's implementation of its National Health Insurance (NHI) program. Under this program, the health insurance coverage rate has reached approximately 99% of the population. Despite guaranteeing the residents of Taiwan equal access regardless of socioeconomic status and background, critical problems and controversies persist, and they continue to challenge the NHI. We analyze the primary issues facing the NHI program with emphasis on financial and consumer behavioral aspects. Furthermore, we apply models from mainland China, South Korea and Singapore to discuss what Taiwan could learn from the systems employed by these countries to modify the NHI. Targeting the needs of the NHI, we have three policy recommendations: separating the NHI scheme into different target populations, strengthening the NHI referral system and regulating the access of overseas citizens to health services while in Taiwan. After two decades in existence, problems persist and there is a continuing need to improve Taiwan's NHI. Copyright © 2016 John Wiley & Sons, Ltd.

Identifying Associations Between State Medicaid Expansion Decisions and Spatial Disparities in County Insurance Rate Changes Under the Affordable Care Act

By the end of 2014, twenty-four states rejected Medicaid expansion, providing a unique opportunity to examine changes in insurance coverage rates after the implementation of the Affordable Care Act within and between states that did versus did not expand Medicaid. Using multilevel regression analyses of county-level non-elderly adult small area health insurance estimates (N = 3135) from the US Census Bureau, several important findings emerge. Compared to counties located in states that did not expand Medicaid, counties located in states that did expand experienced significantly larger increases in adult health insurance coverage rates between 2013 and 2014, net of the county baseline insurance coverage rate, socioeconomic and demographic composition, and labor market characteristics. In states that did not expand Medicaid, counties with larger shares of vulnerable residents (i.e., poor adults and low education) experienced lagging improvements in health insurance coverage. However, counties in states that expanded Medicaid were protected from several of these exacerbated disparities, and in some cases, experienced larger insurance coverage improvements than counties with less disadvantaged populations. These findings suggest that although insurance coverage increased in nearly all counties between 2013 and 2014, increases would have been larger and disparities would have been further alleviated if more states with highly concentrated vulnerable populations had expanded Medicaid.