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We adopt a standard distributional impact methodology, based on Atkinson's cost of inequality approach, to estimate the degree of implicit redistribution created through public funding of health insurance in Canada. The first stage of the exercise is to determine the public health insurance benefits received by families of various age and composition and to add these to measured after-tax incomes. In our base case, which uses the Atkinson Mean Logarithmic Deviation as inequality index, we find that accounting for public health insurance benefits implies a reduction in inequality equivalent to 2.4% of per capita income. We then model the implications of moving to a hypothetical fully privatized system while proportionately refunding to individuals the tax revenues saved in doing so. This would give rise to a further 2.4% equivalent per capita income reduction resulting from increased inequality in the distribution of after-tax income. Thus, for this scenario, moving from public financing of health insurance in Canada to a fully privatized system implies an overall increase in inequality equivalent to a loss of 4.8% of per capita income. This corresponds to an increase of about 25% in existing inequality. Not surprisingly, the impact of publicly financed health insurance in reducing inequality is strongest for the elderly.

This study evaluates whether sociodemographic characteristics, political affiliation, family-related circumstances, self-reported health status, and access to health insurance affect public opinion toward the current US health-care system. Opinions about the health-care system were measured in terms of consumer confidence and perceived need for health-care reform. Data come from the 2008 Cooperative Congressional Election Study (CCES), a nationwide survey of 1,000 respondents. All data were collected in November 2008, thus providing a useful alternative to volatile polling data because they were collected prior to and are thus immune to the polarized tone of the debates that have occurred over the past few years. Overall, we found that public confidence in medical technology and quality of care were consistently high, while confidence in the affordability of medical care was much lower among respondents. Younger adults, those with poor health, and those without health insurance had particularly low confidence in their ability to pay for health care. Although a strong majority of the population agreed that the US health-care system was in need of major reform, support for particular types of government-sponsored health insurance programs was primarily determined by political affiliation. In an era where a large proportion of the population has little access to health care (due to lack of insurance) and where the US government is facing tremendous opposition to the implementation of major reform efforts, it is useful to understand which subgroups of the population are most confident in the current health-care system and most likely to support reform efforts, as well as those who are most resistant to change given their precarious health needs, their inability to access health care (as a result of insurance or noninsurance), or their political affiliation.

In this chapter we examine how micro- and macro-level issues including access to child-only or family public health insurance shape low-income immigrant families’ health care experiences in two policy contexts in the Washington, DC metropolitan area.

This qualitative study includes 40 in-depth interviews with first-generation, low-income immigrant Latin American and African mothers in DC and Northern Virginia.

The majority of families living in Virginia had child-only health insurance, whereas most of the families living in Washington, DC, had family health insurance. Regardless of these insurance differences, all mothers had access to free health care for prenatal care. Pregnancy, for most, was their entry into the U.S. health care system. Families’ ongoing health care experiences differed in relation to insurance access, and culture, including parents’ previous experiences with health care in their countries of origin.

Future research should consider the experiences of other immigrant groups, mental health experiences of immigrants, and fathers’ experiences with health care.

Future initiatives to address health care should focus on providing family health care to low-income immigrant families across the country, improving access to mental health services for immigrant families, and creating more culturally and linguistically appropriate health care services.

This study points to the importance of family health care for immigrant families, as well as care that is culturally and linguistically competent.

This study illustrates the need for public family health insurance for low-income immigrant families, and the importance of culturally competent health care for immigrants.

Access to health care, particularly for children, remains a topic of great importance to policy makers in the United States. Recent attention focuses primarily on the enactment and subsequent expansions of the Children’s Health Insurance Program (CHIP) (Kenney, Ullman & Weil, 2000). Though the legislation affects all qualifying low-income children, the unique service needs of children with disabilities justify a closer look at the relationship between health insurance, income, and needs amongst children with disabilities. This analysis seeks to answer the following questions. To what extent do children with disabilities need various supportive health services? Does this need vary across type of disability or income level? Do children with health insurance, either public or private, have fewer unmet needs than children without health insurance? Answers to these questions will assist policy makers when determining who should be targeted to receive additional assistance in the future as well as evaluate the effectiveness of current mechanisms in delivering supportive health services to children with disabilities.

If rational individuals pay the full costs of their decisions about food intake and exercise, economists, policy makers, and public health officials should treat the obesity epidemic as a matter of indifference. In this paper, we show that, as long as insurance premiums are not risk rated for obesity, health insurance coverage systematically shields those covered from the full costs of physical inactivity and overeating. Since the obese consume significantly more medical resources than the non-obese, but pay the same health insurance premiums, they impose a negative externality on normal weight individuals in their insurance pool.

To estimate the size of this externality, we develop a model of weight loss and health insurance under two regimes – (1) underwriting on weight is allowed and (2) underwriting on weight is not allowed. We show that under regime (1), there is no obesity externality. Under regime (2), where there is an obesity externality, all plan participants face inefficient incentives to undertake unpleasant dieting and exercise. These reduced incentives lead to inefficient increases in bodyweight, and reduced social welfare.

Using data on medical expenditures and bodyweight from the National Health and Interview Survey and the Medical Expenditure Panel Survey, we estimate that, in a health plan with a coinsurance rate of 17.5%, the obesity externality imposes a welfare cost of about $150 per capita. Our results also indicate that the welfare loss can be reduced by technological change that lowers the pecuniary and non-pecuniary costs of losing weight, and also by increasing the coinsurance rate.

This chapter reviews the existing empirical evidence on how social insurance affects health. Social insurance encompasses programs primarily designed to insure against health risks, such as health insurance, sick leave insurance, accident insurance, long-term care insurance, and disability insurance as well as other programs, such as unemployment insurance, pension insurance, and country-specific social insurance programs. These insurance systems exist in almost all developed countries around the world. This chapter discusses the state-of-the art evidence on each of these social insurance systems, briefly reviews the empirical methods for identifying causal effects, and examines possible limitations to these methods. The findings reveal robust and rich evidence on first-stage behavioral responses (“moral hazard”) to changes in insurance coverage. Surprisingly, evidence on how changes in coverage impact beneficiaries’ health is scant and inconclusive. This lack of identified causal health effects is directly related to limitations on how human health is typically measured, limitations on the empirical approaches, and a paucity of administrative panel data spanning long-time horizons. Future research must be conducted to fill these gaps. Of particular importance is evidence on how these social insurance systems interact and affect human health over the life cycle.

Most women seeking abortion pay out-of-pocket for care, partly due to legal restrictions on insurance coverage. These costs can constitute a hardship for many women. Advocates have sought to ensure insurance coverage for abortion, but we do not know whether the intermediaries between policy and patient – abortion-providing facilities – are able and willing to accept insurance.

We interviewed 22 abortion facility administrators, representing 64 clinical sites in 21 states that varied in their legal allowance of public and private insurance coverage for abortion, about their facility’s insurance practices, and experiences.

Respondents described challenges in accepting public and/or private insurance that included, but were not limited to, legal regulations. When public insurance broadly covered abortion, its low reimbursement failed to cover the costs of care. Because of the predominance of low income patients in abortion care, this caused financial challenges for facilities, leading one in a state that allows broad coverage to nonetheless decline public insurance. Accepting private insurance carried its own risks, including nonpayment because costs fell within patients’ deductibles. Respondents described work-arounds to protect their facility from nonpayment and enable patients to use their private insurance.

The structure of insurance and the population of abortion patients mean that changes at the political level may not translate into changes in individual women’s experience of paying for abortion.

This research illustrates how legal regulations, insurer practices, and the socioeconomics of the patient population matter for abortion-providing facilities’ decision-making about accepting insurance.

This study examines the effect of a Medicaid disenrollment on employment, sources of health insurance coverage, and health and health care utilization of childless adults using longitudinal data from the 2004 Panel of the Survey of Income and Program Participation. From July to September 2005, TennCare, the Tennessee Medicaid program, disenrolled approximately 170,000 adults following a change in eligibility rules. Following this eligibility change, the fraction of adults in Tennessee covered by Medicaid fell by over 5 percentage points while uninsured rates increased by almost 5 percentage points relative to adults in other Southern states. There is no evidence of an increase in employment rates in Tennessee following the disenrollment. Self-reported health and access to medical care worsened as hospitalization rates, doctor visits, and dentist visits all declined while the use of free or public clinics increased. The Tennessee experience suggests that undoing the expansion of Medicaid eligibility to adults that occurred under the Affordable Care Act likely would reduce health insurance coverage, reduce health care access, and worsen health but would not lead to increases in employment.

While the Affordable Care Act (ACA) promised to reduce inequalities in insurance coverage between Latinos and non-Latinos by expanding coverage, it also excluded a large portion of noncitizen immigrants. Past research has demonstrated that among Latinos, further inequalities have developed between citizens and noncitizens after the ACA took effect, but it is unclear if this pattern is unique to Latinos or is evident among non-Latinos as well. I use data from the 2011 to 2016 waves of the National Health Interview Survey (NHIS) (n = 369,386) to test how the relationship between citizenship status (native citizen, naturalized citizen, or noncitizen) and insurance coverage changed after the ACA, adjusting for health, demographic, and socioeconomic factors. I disaggregate the analysis by ethnicity to test whether this change differs between Latinos and non-Latinos. The analysis finds that after the ACA, naturalized citizens across ethnic groups moved toward parity with native citizens in health insurance coverage while the benefits of the ACA for noncitizens were conditional on ethnicity. For non-Latinos, lacking citizenship became less disadvantageous for predicting insurance coverage while for Latinos, lacking citizenship became even more disadvantageous in predicting insurance coverage. This bifurcation among noncitizens by ethnicity implies that while the ACA has strengthened institutional boundaries between citizens and noncitizens, this distinction is primarily affecting Latinos. The conclusion offers considerations on how legal systems of stratification influence population health processes.

To examine associations by gender between cancer history and major health insurance transitions (gains and losses), and relationships between insurance transitions and access to care.

Longitudinal 2008–2013 Medical Expenditure Panel Survey data were pooled yielding 2,223 cancer survivors and 50,692 individuals with no cancer history ages 18–63 years upon survey entry, with gender-specific sub-analyses. Access-to-care implications of insurance loss or gain were compared by cancer history and gender.

Initially uninsured cancer survivors were significantly more likely to gain insurance coverage than individuals with no cancer history (RR: 1.25; 95% CI: 1.08–1.44). Females in particular were significantly more likely to gain insurance (unmarried RR: 1.16; 95% CI: 1.06–1.28; married RR: 1.09; 95% CI: 1.02–1.16). Significantly higher rates of difficulty accessing needed medical care and prescription medications were reported by those remaining uninsured, those who lost insurance, and women in general. Remaining uninsured, losing insurance, and male gender were associated with lack of a usual source of care.

Additional outreach to disadvantaged populations is needed to improve access to affordable insurance and medical care. Future longitudinal studies should assess whether major Affordable Care Act (ACA) provisions enacted after the 2008–2013 study period (or those of ACA’s replacement) are addressing these important issues.

Loss of health insurance coverage can reduce health care access resulting in poor health outcomes. Cancer survivors may be particularly at risk of insurance coverage gaps due to the long-term chronic disease trajectory. This study is novel in exploring associations between cancer history by gender and health insurance transitions, both gains and losses, in a national non-elderly adult sample.