Uninsured Hospital Research Articles

Associations of Medicaid Expansion With Access to Care, Severity, and Outcomes for Acute Ischemic Stroke.

Multiple states have not expanded Medicaid under the Affordable Care Act, resulting in higher uninsured rates in states with high stroke burdens. This study aimed to evaluate the association of Medicaid expansion with changes in health insurance coverage, severity of presentation, access to care, and outcomes among patients with acute ischemic stroke. A retrospective, difference-in-differences analysis of Get With The Guidelines-Stroke registry data. The study population comprised first-time ischemic stroke admissions from 2012 to 2018 for patients aged 19 to 64 in 45 states (27 that expanded Medicaid and 18 that did not). A probable low-income cohort was defined based on having Medicaid, no insurance/self-pay, or undocumented insurance. Outcomes analyzed were indicators of health insurance status, stroke severity, use of emergency services, time to acute care, in-hospital mortality, receipt of rehabilitation, discharge disposition, and level of disability. In the starting population (N=342 765), Medicaid-covered stroke admissions rose from 12.2% to 18.1% in expansion states and from 10.0% to only 10.6% in nonexpansion states, while uninsured admissions declined from 15.0% to 6.7% in expansion states and from 24.0% to 19.2% in nonexpansion states. In the low-income cohort (N=95 086; 28% of starting population), Medicaid expansion was associated with increased odds of discharge to a skilled nursing facility (adjusted odds ratio, 1.33 [95% CI, 1.12-1.59]) and transfer to any rehabilitation facility among those eligible (adjusted odds ratio, 1.24 [95% CI, 1.08-1.41]) and lower odds of discharge home (adjusted odds ratio, 0.89 [95% CI, 0.80-0.98]). Expansion was not associated with any other outcomes. Medicaid expansion is associated with fewer uninsured hospitalizations for acute ischemic stroke and increased rehabilitation at skilled nursing facilities. More targeted interventions may be needed to improve other stroke outcomes in the low-income US population. Future research should evaluate the impact of health care reform on primary stroke prevention.

The Economic Consequences of Bankruptcy Reform

A more generous consumer bankruptcy system provides greater insurance against financial risks but may also raise the cost of credit. We study this trade-off using the 2005 Bankruptcy Abuse Prevention and Consumer Protection Act (BAPCPA), which increased the costs of filing for bankruptcy. We identify the effects of BAPCPA on borrowing costs using variation in the effects of the reform across credit scores. We find that a one-percentage-point reduction in bankruptcy filing risk decreased credit card interest rates by 70–90 basis points. Conversely, BAPCPA reduced the insurance value of bankruptcy, with uninsured hospitalizations 70 percent less likely to obtain bankruptcy relief after the reform. (JEL D18, G15, I13, K35)

Disparities in insurance coverage among hospitalized adult congenital heart disease patients before and after the Affordable Care Act.

Data are lacking regarding the insurance status of adults with congenital heart disease (ACHD). We investigated whether the Affordable Care Act (ACA) impacted insurance status among hospitalized ACHD, identified associated sociodemographic factors, and compared coverage to adults with other chronic childhood conditions. Serial cross-sectional analysis of National Inpatient Sample hospitalizations from 2007 to 2016 was performed for patients 18-64 years old. ACHD were identified using ICD-9/10-CM codes and compared to patients with sickle cell disease (SCD), cystic fibrosis (CF), and the general population. Age was dichotomized as 18-25 years (transition aged) or 26-64 years. Groups were compared by era (pre-ACA [January 2007-June 2010]; early-ACA [July 2010-December 2013], which eliminated pre-existing condition exclusions; and full-ACA [January 2014-December 2016]) using interrupted time series and multivariable Poisson regression analyses. Overall, uninsured hospitalizations decreased from pre-ACA (12.0%) to full-ACA (8.5%). After full ACA implementation, ACHD had lower uninsured rates than the general hospitalized population (6.0 vs. 8.6%, p < .01), but higher rates than those with other chronic childhood diseases (SCD [4.5%]; CF [1.6%]). Across ACA eras, transition aged ACHD had higher uninsured rates than older patients (8.9 vs. 7.6%, p < .01), and Hispanic patients remained less insured than other groups. Hospitalized ACHD were better insured than the general population but less insured than those with SCD or CF. Full ACA implementation was associated with improved insurance coverage for all groups, but disparities persisted for transition aged and Hispanic patients. Ongoing evaluation of the effects of insurance and health policy on ACHD remains critical to diminish health disparities.

Association of State Medicaid Expansion With Rate of Uninsured Hospitalizations for Major Cardiovascular Events, 2009-2014.

Cardiovascular disease is the leading primary diagnosis among all hospital discharges, and insurance status is associated with patient outcomes. The association of state-level policy decisions regarding the Affordable Care Act (ACA) Medicaid expansion with rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality has not been investigated to date. To investigate whether the rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality varied by state-level policy on ACA Medicaid expansion. For this cohort study, difference-in-differences analysis of data from the Healthcare Cost and Utilization Project State Inpatient Databases of 30 US states on 524 848 non-Medicare hospitalizations in 2014 and a mean of 516 811 non-Medicare hospitalizations per year from 2009 to 2013 was performed for major cardiovascular events (defined as a composite of acute myocardial infarction, stroke, and heart failure) from January 1, 2009, through December 31, 2014. Analyses were completed September 1, 2017. State Medicaid expansion as of January 1, 2014. Comparison of mean payer mix proportions (uninsured, Medicaid, and privately insured) and in-hospital mortality between expansion and nonexpansion states for the years preceding the ACA Medicaid expansion (2009-2013) and the year after the ACA Medicaid expansion (2014). Of the 801 819 hospitalizations in the 17 expansion states in 2014, 428 503 (53.4%) patients were men, 514 036 (64.1%) were white, and 365 797 (45.6%) were aged 65 to 84 years. Of 719 459 hospitalizations in the 13 nonexpansion states in 2014, 383 311 (53.3%) patients were men, 492 136 (68.4%) were white, and 335 781 (46.7%) were aged 65 to 84 years. There were 281 184 non-Medicare hospitalizations for major cardiovascular events in the 17 expansion states and 243 664 non-Medicare hospitalizations in the 13 nonexpansion states in 2014. In multivariable regression analyses, the expansion states had a significant 5.8-percentage point decrease in the proportion of uninsured hospitalizations after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, -0.058; 95% CI, -0.075 to -0.042; P < .001). The expansion states also had a significant 8.4-percentage point increase in the Medicaid share after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, 0.084; 95% CI, 0.065 to 0.102; P < .001). In-hospital mortality did not change significantly after Medicaid expansion in either the expansion states (before ACA, 3.8% vs after ACA, 3.7%) or the nonexpansion states (4.0% vs 4.0%). States that expanded Medicaid during the ACA implementation had a significantly greater reduction in the proportion of uninsured hospitalizations for major cardiovascular events compared with the nonexpansion states. This study suggests that expansion status was not associated with in-hospital mortality rates in the first year after ACA implementation.

Abstract 282: The Effect of State Medicaid Expansions on Acute Myocardial Infarction Care Quality and Outcomes

Background: Despite considerable progress in the treatment of acute myocardial infarction (AMI), major disparities in care remain for the uninsured. Lack of insurance is associated with delays in seeking emergency care for AMI, and uninsured patients are less likely to receive guideline-directed medical therapy, invasive cardiac procedures, and have higher mortality rates than their insured counterparts. In 2014, Medicaid eligibility was expanded under the ACA, and millions of low-income adults gained insurance coverage in over 30 states. However, little is known about Medicaid expansions’ impact on the quality and outcomes of inpatient care for AMI. Methods: We studied 325,343 MI patients under 65 years of age treated at 860 hospitals in the ACTION-GWTG Registry between 2012 and 2016. Expansion states were those that implemented ACA Medicaid expansion during 2014. Our pre-expansion period included the two years prior to expansion (1/1/2012 to 12/31/2013) and our post-expansion period included the two years following expansion (1/1/2015 to 12/31/2016). We first characterized trends in AMI hospitalizations by insurance status during the study period in expansion and non-expansion states. We then identified a low-income cohort, defined as being covered by Medicaid or uninsured, and assessed the association between state expansion status and quality and outcome measures stratified by time periods using hierarchical logistic regression models. Results: In our overall cohort, from 2012 to 2016, the proportion of hospitalized AMI patients insured by Medicaid increased by 6.9% in expansion states (7.5% to 14.4%) and 0.4% in non-expansion states (6.2% to 6.6%). Uninsured hospitalizations also declined more in expansion states (18% to 8.4%) than in non-expansion states (25.6% to 21.1%). Our low-income cohort included 55,737 patients - 38,786 were uninsured and 16,951 were insured with Medicaid. Prior to expansion, states that eventually expanded Medicaid were more likely to provide defect free AMI care (all performance measures followed for eligible patients) compared with non-expansion states (aOR 1.26, 95% CI 1.10-1.45, p&lt;0.001). In the post-expansion period, there was no significant difference in defect free AMI care (aOR 1.02, 95% CI 0.89-1.16, p=0.83, p for interaction&lt;0.001). In addition, patients in expansion and non-expansion states had similar rates of in-hospital death both during the pre-expansion period (aOR 0.95, 95% CI 0.79-1.13, p=0.56) and the post-expansion period (aOR 1.03, 95% CI 0.87-1.24, p=0.71, p for interaction=0.48). Conclusions: States that elected to expand Medicaid did not experience significant improvements in AMI care quality or in-hospital mortality compared with non-expansion states.

In Four ACA Expansion States, The Percentage Of Uninsured Hospitalizations For People With HIV Declined, 2012-14.

This study examines the influence of the Affordable Care Act's optional state Medicaid expansion on insurance coverage and health outcomes for hospitalized patients with HIV. I used data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for all hospitalizations of patients with HIV from 2012 through the first six months of 2014 in four states that expanded their Medicaid programs and two states that did not. I found that the percentage of hospitalizations of uninsured people with HIV in the four expansion states fell from 13.7 percent to 5.5 percent in the study period, while the percentage in the two nonexpanding states increased from 14.5 percent to 15.7 percent. I also found that hospitalized patients with HIV who did not have insurance were 40 percent more likely to die during their hospital stays than comparable patients with insurance.

Aggregating administrative and claims data from multiple payers to estimate population-based health outcomes: A validation study.

285 Background: Health insurance claims data are increasingly used for estimating individual health outcomes. However, it is challenging to obtain population-based estimates because of difficulties obtaining and reconciling data from all insurance providers. With incomplete insurance data, methods are needed to estimate the entire insured population. Using multi-payer claims we demonstrate and validate a synthetic method to obtain county level morbidity estimates. Methods: We used data from the Integrated Cancer Information and Surveillance System (ICISS) data resource at the University of North Carolina (NC) at Chapel Hill. ICISS data represent a linked data resource comprised of beneficiaries enrolled in federal as well as private insurance plans and rich ecologic data; and represent 5.5 million unique individuals, about 55% of the NC population. Using specific ICD-9 diagnosis codes, claims data from 2008 were compared to state department of public health data. We computed county level hospitalization rates by summing data from three sub-groups: age 65 and older in the 100% Medicare sample, age younger than 65 in the 100% Medicaid sample, and age younger than 65 represented in the private payer data. For the privately insured population, we used census data to obtain estimates of the entire privately insured population and used the hospitalization rate from beneficiaries in ICISS data to estimate a numerator for the synthetic sample of privately insured beneficiaries. We used State Inpatient Data (SID) from NC County Data Book to validate our method. Results: Overall, our synthetic approach showed moderate to high validity with a Pearson correlation coefficient 0.77 for heart disease and 0.93 for flu or pneumonia. Our hospitalization estimates were slightly lower than the data from SID, because SID data include uninsured individuals and multiple hospitalizations for individuals. Conclusions: Our synthetic method can be useful in estimating population-based health outcomes using linked insurance claims data.

Use of Inpatient Imaging Services by Persons Without Health Insurance

Americans without health insurance generally receive fewer health care services than those with insurance. Less studied are the specific types of services for which the uninsured face access and utilization differences. This article fills in some of the knowledge gaps by presenting comparisons between uninsured and insured individuals in the use of imaging services in the hospital inpatient setting. The primary data source for this study was the 2003 National Hospital Discharge Survey. The principal source of payment was used to define insurance status. Global relative value units were assigned by imaging procedure. To ensure sufficient numbers of observations, individual imaging procedures were aggregated into 6 modalities. Multivariate regression was used to estimate the utilization and value of imaging services as a function of insurance status and other control variables. Just over 9% of inpatients were uninsured (range, 15.7% aged 18-24 years to 5.8% aged 55-64 years). After controlling for measurable factors, uninsured hospital inpatients who underwent imaging received the same mean number of imaging services (1.51) of the same mean value (11 relative value units) as those for comparable insured persons. The uninsured received fewer interventional and image-guided procedures but more CT studies than insured patients (P < .05). Because insurance status does not seem to significantly influence the quantity or value of imaging services received by hospital inpatients who receive imaging, efforts to assist uninsured patients with imaging needs would be better directed elsewhere than the hospital inpatient setting.

Battling the Uncompensated Care Spiral

The purpose of this research was to evaluate the effectiveness of financial counseling services in assisting uninsured patients receive financial assistance and medical insurance. A single, nonprofit 400+-bed, inner-city, acute care facility in the Mountain West. A retrospective, medical record review design was used. Records for any uninsured patients admitted as inpatients to the hospital were considered for the study. A sample of 50 records was selected by evaluating every 21st patient from a chronological list of 1,070 possible records of all uninsured patients admitted to the facility during the months of May through July 2006. A tool was created for this study and used by the principal investigator (H.B.) to abstract specific points of data from each patient record. The research was approved by the university institutional review board. Descriptive statistical analyses were then performed to determine trends. Financial counseling at this institution aided 55% of uninsured patients to obtain health insurance. Because insurance was obtained for previously uninsured patients, the institution was reimbursed a total of $865,350. The institution was left with a total of $388,291 in uncompensated care. Patients younger than 18 years and patients admitted to labor and delivery or newborn nursery units obtained insurance coverage more often than other patients. Insurance counseling for uninsured hospital patients has proven to be effective. The patient benefits from the counseling by obtaining insurance and the hospital benefits by receiving more financial reimbursement for services given. Case managers have a great opportunity to help their uninsured patients by offering insurance counseling. Case managers should familiarize themselves with all possible health insurance options so that they can advise and guide patients through these application processes.

Uninsured Hospitalizations: Rural and Urban Differences

Few studies have examined hospitalization patterns among the uninsured, especially from the perspective of rural and urban differences. To examine whether the patterns of uninsured hospitalizations differ in rural and urban hospitals and to identify the most prevalent and costly diagnoses among uninsured hospitalizations. We conducted a cross-sectional analysis of the Healthcare Cost and Utilization Project's National Inpatient Sample representing a total of 37,804,021 hospital discharges, with 4.9% of them generated by uninsured persons in 2002. We compared demographic and clinical characteristics and the proportion of frequent and costly diagnoses by rural and urban hospitals. We used multiple logistic regression models to examine the relationship between preventable conditions and rural and urban hospitals among uninsured hospitalizations. Uninsured persons discharged from rural hospitals were more likely than their urban counterparts to be working-age adults (82% vs 79%) and to reside in a ZIP code area with a median household income of less than $35,000 per year (56% vs 26%). Rural uninsured hospitalizations were more likely to be for preventable conditions than were urban uninsured hospitalizations (P < .001). The proportion of total hospital charges related to preventable hospitalizations was 15.5% in rural hospitals versus 10.0% in urban hospitals. The patterns of uninsured hospitalizations in rural and urban hospitals were different in many ways. Providing adequate access to primary care could result in potential savings related to preventable hospitalizations for the uninsured, especially for rural hospitals.

The Effect of Market Reform on Racial Differences in Hospital Mortality

Journal of General Internal MedicineVolume 21, Issue 11 p. A‐10-A‐10 Free Access The Effect of Market Reform on Racial Differences in Hospital Mortality First published: 02 October 2006 https://doi.org/10.1111/j.1525-1497.2006.00484_1.x Address correspondence and requests for reprints to Dr. Volpp: CHERP, Philadelphia Veterans Affairs Medical Center, 9th Floor, University and Woodland Avenues, Philadelphia, PA 19104. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract In this study, we examined whether a reform passed in New Jersey that reduced subsidies for uninsured hospital care and changed hospital payment from rate regulation to price competition worsened racial differences in mortality outcomes for 7 conditions. The relative increase in mortality among blacks in New Jersey was significantly larger than among whites for acute myocardial infarction (2.4% points vs. 0.1% points, P-value for difference .026) but not for the other 6 conditions. We conclude that market-based reform may contribute to racial disparities in mortality but we do not find consistent evidence that this is the case. Volume21, Issue11November 2006Pages A‐10-A‐10 RelatedInformation

Development of a health care policy characterisation model based on use of private health insurance

ObjectiveThe aim of this study was to develop a policy characterisation process based on measuring shifts in use of private health insurance (PHI) immediately following implementation of changes in federal health care policy.MethodPopulation-based hospital morbidity data from 1980 to 2001 were used to produce trend lines in the annual proportions of public, privately insured and privately uninsured hospital separations in age-stratified subgroups. A policy characterisation model was developed using visual and statistical assessment of the trend lines associated with changes in federal health care policy.ResultsOf eight changes in federal health care policy, two (introduction of Medicare and Lifetime Health Cover) were directly associated with major changes in the trend lines; however, minor changes in trends were associated with several of the other federal policies. Three types of policy effects were characterised by our model: direction change, magnitude change and inhibition. Results from our model suggest that a policy of Lifetime Health Cover, with a sanction for late adoption of PHI, was immediately successful in changing the private: public mix. The desired effect of the 30% rebate was immediate only in the oldest age group (70+ years), however, introduction of the lifetime health cover and limitations in the model restricted the ability to determine whether or if the rebate had a delayed effect at younger ages.ConclusionAn outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy.

Hospitalization for Firearm-Related Injuries in the United States, 1997

Background Firearm-related injuries are a serious public health problem in the United States. Despite the magnitude of this problem, prior national estimates of nonfatal, firearm-related morbidity have been limited to an emergency department–based surveillance system. The objective of this study was to assess and report the information available on firearm-related injuries in an existing national database, derived from hospital discharge data. Methods Cross-sectional analysis of the 1997 Nationwide Inpatient Sample (NIS), a stratified probability sample of 1012 nonfederal community hospitals from 22 states. The database was queried using E codes to identify firearm-related injuries. The SUDAAN software program was used to convert raw counts into weighted counts that represent national estimates and 95% confidence intervals (CIs). Results An estimated 35,810 (95% CI, 32,615–38,947) cases nationwide were identified, of which 86% were male. Assault was the leading cause of firearm-related hospitalization, followed by unintentional injury. The mean length of stay (LOS) for patients with a firearm-related assault was 6 days. Seven percent of all firearm cases died during the hospitalization. The total estimated hospital charges for firearm-related injuries in the United States in 1997 was over $802 million, and 29% of the patients admitted for this condition were uninsured. Conclusions Firearm-related injuries rank highest among all conditions in the number of uninsured hospital stays, and the average LOS is much longer compared to other medical conditions. National estimates derived from the NIS are consistent with previous estimates, and NIS provides additional information not available from other data sources.

Comparing Uninsured and Privately Insured Hospital Patients: Admission Severity, Health Outcomes and Resource use

This paper compares uninsured hospital patients with privately insured patients in terms of severity of illness on admission, emergency department use, leaving the hospital against medical advice, length of stay, and in-hospital mortality and morbidity rates. This cross-sectional study includes 29 237 admissions to 100 US hospitals in 1993 and 1994. We found that uninsured patients are sicker, indicating that hospitals should expect uninsured patients to have increased service needs. Our results indicate that the uninsured exhibit higher likelihood of leaving against medical advice, shorter lengths of stay and poorer health outcomes suggest that the uninsured may not be receiving necessary care. Further studies are needed.

Information Costs and Health Insurance Contracts

ABSTRACT This article develops an equilibrium pricing model examining the nature of health insurance contracts by considering the relationship between information about risk types and equilibrium prices. Both community-rated (pooling) and risk-rated (separating) premia may co-exist under certain conditions, given that the insurer can observe the real risk type of the insured by spending some fixed amount on information. The higher the costs of determining risk class, the more heterogeneous will be the risk types offered insurance at the same (or pooling) premium. Also, the higher the mean and variance of the risk type distribution for the population, the more relatively healthy insureds would prefer risk-rated contracts to community-rated contracts. INTRODUCTION The issue of equilibrium pricing under adverse selection has received much attention. Most studies show different equilibria of either community-rated (pooling) contracts or risk-rated (separating) contracts based on sorting of risk types (Akerlof, 1970; Rothschild and Stiglitz, 1976; Wilson, 1977; Miyazaki, 1977). An equilibrium pricing policy taking the form of community-rated contracting means that each member of the community pays the same premium independently of whether the individual is perceived to be a high health risk or a low health risk. Risk-rated contracts establish a premium appropriate for each insured's expected medical costs. In American voluntary health insurance markets, premium setting is risk-rated for individuals and groups on the basis of indicators such as age, sex, occupation, and previous health condition. [1] Also, the risk-rated structure differs in terms of individual, small group, and large group plans (Light, 1992; Gauthier et al., 1995). Unlike with large groups organized for purposes other than health insurance, there is no reason to pool individual plans except for purposes of health insurance. Providers of individual plans try to avoid adverse selection by taking steps to screen potential insureds--e.g., examining medical records, excluding pre-existing conditions from coverage, and limiting the provider's maximum exposure. In the limit, risk-rated contracts establish a premium for each insured appropriate to that insured's expected medical costs during the life of the contract. Thus, in the individual market the insurer would tend to charge very expensive plans for those few disadvantaged by poor health. [2] This result might explain the fact that risk-rated policies tend to result in a growing number of uncovered medical conditions and uninsured doctor and hospital bills. Like individual plans, small group plans make it more difficult to diffuse risks than do large plans. When a group gets larger, the average expected medical cost would be less likely to vary. According to Aaron and Bosworth, insurance premium for groups of fewer than 10 employees commonly are 25 to 30 percent above those for groups of 50 or more. Also, around 73 percent of small firms with fewer than 10 employees did not offer health insurance in 1990. In contrast, only 2 percent of large firms with more than 100 employees did not provide health insurance (Aaron and Bosworth, 1994). This article develops an equilibrium pricing model examining the nature of health insurance contracts by considering the relationship between information about risk type and price equilibrium, given different assumptions about individual health states, risk types, and adverse selection. The author shows that either a pooling or a mixed equilibrium is possible, based on the assumption of equilibrium concept suggested by Wilson (1977). [3] The assumption of asymmetric information at the time of contracting means that information costs are critical to determining the type of equilibrium policy because it is costly to collect detailed information on the riskiness of individual customers. [4] Between a community-rated policy without verification costs and a risk-rated policy with verification costs, insureds will choose the policy with the smaller premium. …

Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States–1999

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

Counting the uninsured using state-level hospitalization data.

To assess the appropriateness of using state-level data on uninsured hospitalizations to estimate the uninsured population. The authors used 1992-1996 data on hospitalizations of newborns and of appendectomy and heart attack patients in Florida to estimate the number of people in the state without health insurance coverage. These conditions were selected because they usually require hospitalization and they are common across demographic categories. Adjusted for the gender and ethnic composition of the population, the percentages of uninsured hospitalizations for appendectomies and heart attacks produced estimates of the state's uninsured population 1.6 percentage points lower than those reported for 1996 in the US Census March Current Population Survey. Data reported by hospitals to state agencies can be used to monitor trends in health insurance coverage and provides an alternative data source for a state-level analysis of the uninsured population.

The Uninsured Consumer and Hospital Choice

The term "choice" has played an important role in the ongoing debate over health care reform in the United States. One of the major assumptions underlying reform efforts is that affordability drives consumers' choice of health care providers, particularly for the uninsured. In the state of Maryland, the issue of affordability is addressed by an "all-payor" system. In such a scenario, where enhanced choice opportunities are available for the uninsured, such consumers seem to be making choices which lead to the use of hospitals other than those which would be predicted based upon convenience or closeness of location alone.

Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area

Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area

Case Mix and Resource Utilization by Uninsured Hospital Patients in the Boston Metropolitan Area

Rising competitive pressures may place uninsured patients at risk for receiving fewer services than insured patients with similar medical conditions. To examine this possibility we studied the case mix, length of stay, and number of procedures for 65,032 patients listed as self-pay or free care, Blue Cross, or Medicaid at 52 hospitals in the Boston, Mass, area during 1983. We found that the overall case mix severity index (based on expected length of stay per diagnosis related group) for uninsured patients was 30% higher in public hospitals and 8% higher in major teaching hospitals compared with other institutions. Across all hospitals, the severity index of uninsured patients was similar to that of insured patients. However, after adjusting for diagnosis related group case mix, uninsured patients had, on average, 7% shorter stays (5.36 vs 5.79 days) and underwent 7% fewer procedures (1.16 vs 1.25) than Blue Cross patients, the differences varying with hospital type. Uninsured patients also had shorter stays on average than Medicaid patients (5.36 vs 5.87 days), but they underwent a similar number of procedures. These results suggest that patients who lack insurance may receive unequal treatment even after being hospitalized.