Workers Who Decline Employment-Related Health Insurance

A conceptual model of health insurance stability in the United States health care system

In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.

Selection in employer sponsored health insurance

This paper examines the extensive margin of selection into employer-sponsored health insurance (ESHI) using data from the Medical Expenditures Panel Survey 2001-2010 and 2014-2016 and the National Longitudinal Survey of Youth'97 in 2010. Controlling for a large set of firm and job characteristics, I find that before the implementation of the Affordable Care Act (ACA) in 2014, workers aged 25-40 who declined ESHI and remained privately uninsured had significantly higher health risk than those who enrolled. No correlation between health and insurance take-up is found in the 41-64 age group. These results are partly explained by differences in income and Medicaid crowding out ESHI for high risk workers. The paper sheds light on the characteristics of uninsured workers, their incentives for declining insurance and the interaction between private and public health insurance. The allocation of ESHI remained unchanged after the ACA was introduced due to the provisions' counteracting effects.

Examining public knowledge and preferences for adult preventive services coverage

Introduction

To examine (1) what individuals know about the existing adult preventive service coverage provisions of the Affordable Care Act (ACA), and (2) which preventive services individuals think should be covered without cost sharing.

Methods

An online panel from Survey Monkey was used to obtain a sample of 2,990 adults age 18 and older in March 2015, analyzed 2015–2017. A 17-item survey instrument was designed and used to evaluate respondents’ knowledge of the adult preventive services provision of the ACA. Additionally, we asked whether various preventive services should be covered. The data include age, sex, race/ethnicity, and educational attainment as well as measures of political ideology, previous insurance status, the number of chronic conditions, and usual source of care.

Results

Respondents correctly answered 38.6% of the questions about existing coverage under the ACA, while on average respondents thought 12.1 of 15 preventive services should be covered (SD 3.5). Respondents were more knowledgeable about coverage for routine screenings, such as blood pressure (63.4% correct) than potentially stigmatizing screenings, such as for alcohol misuse (28.8% correct). Blood pressure screening received the highest support of coverage (89.8%) while coverage of gym memberships received the lowest support (59.4%). Individuals with conservative ideologies thought fewer services on average should be covered, but the difference was small—around one service less than those with liberal ideologies.

Conclusions

Overwhelmingly, individuals think that most preventive services should be covered without cost sharing. Despite several years of coverage for preventive services, there is still confusion and lack of knowledge about which services are covered.

The association of treatment of depressive episodes and work productivity

OBJECTIVE

About one-third of the annual $51 billion cost of mental illnesses is related to productivity losses. However, few studies have examined the association of treatment and productivity. The purpose of our research is to examine the association of depression and its treatment and work productivity.

METHODS

Our analyses used data from 2737 adults aged between 18 and 65 years who participated in a large-scale community survey of employed and recently employed people in Alberta. Using the World Health Organization's Health and Work Performance Questionnaire, a productivity variable was created to capture high productivity (above the 75th percentile). We used regression methods to examine the association of mental disorders and their treatment and productivity, controlling for demographic factors and job characteristics.

RESULTS

In the sample, about 8.5% experienced a depressive episode in the past year. The regression results indicated that people who had a severe depressive episode were significantly less likely to be highly productive. Compared with people who had a moderate or severe depressive episode who did not have treatment, those who did have treatment were significantly more likely to be highly productive. However, about one-half of workers with a moderate or severe depressive episode did not receive treatment.

CONCLUSIONS

Our results corroborate those in the literature that indicate mental disorders are significantly associated with decreased work productivity. In addition, these findings indicate that treatment for these disorders is significantly associated with productivity. Our results also highlight the low proportion of workers with a mental disorder who receive treatment.

Uncompensated care provided by for-profit, not-for-profit, and government owned hospitals

Background

There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals.

Methods

We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served.

Results

Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth.

Conclusions

For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.

Children's receipt of health care services and family health insurance patterns

PURPOSE

Insured children in the United States have better access to health care services; less is known about how parental coverage affects children's access to care. We examined the association between parent-child health insurance coverage patterns and children's access to health care and preventive counseling services.

METHODS

We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002-2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children's unmet health care and preventive counseling needs.

RESULTS

Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02-2.97), no usual source of care (OR = 1.31; 95% CI, 1.10-1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01-1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04-1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.

CONCLUSIONS

Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.

Are Adults in Poor Health More Likely to Enroll in Public Insurance?

Policies to reduce the number of uninsured people are rarely judged by whether they will increase insurance coverage rates among the chronically ill, despite evidence suggesting that the health benefits of coverage are greatest for these individuals. This paper examines the effect of public coverage expansions on insurance take-up and unmet need by low-income mothers in poor health. We find a 14.3-percentage-point reduction in unmet need among mothers reporting fair or poor health status. Our results suggest that some of this reduction is due to individuals moving from inadequate private coverage to public coverage.

Uninsured children and adolescents with insured parents

CONTEXT

Millions of US children and adolescents lack health insurance coverage. Efforts to expand their insurance often focus on extending public coverage to uninsured parents. Less is known about the uninsured whose parents already have coverage.

OBJECTIVE

To identify predictors of uninsurance among US children and adolescents with insured parents.

DESIGN AND SETTING

Cross-sectional and full-year analyses of pooled 2002-2005 data from the nationally representative Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Children and adolescents younger than 19 years in 4 yearly MEPS files with positive full-year weights who had at least 1 parent residing in the same household. There were 39,588 in the unweighted cross-sectional analysis and 39,710 in the unweighted full-year analysis.

MAIN OUTCOME MEASURE

Prevalence of uninsurance among children and adolescents with at least 1 insured parent; predictors of uninsurance among children with at least 1 insured parent.

RESULTS

In the cross-sectional study population, 1380 of 39,588 children and adolescents were uninsured with at least 1 insured parent (weighted prevalence, 3.3%; 95% confidence interval [CI], 3.0%-3.6%). In multivariate analyses of children and adolescents with at least 1 insured parent, those uninsured were more likely Hispanic (odds ratio [OR], 1.58; 95% CI, 1.23-2.03) than white, non-Hispanic; low income (OR, 2.02; 95% CI, 1.42-2.88) and middle income (OR, 1.48; 95% CI, 1.09-2.03) than high income; from single-parent homes (OR, 1.99; 95% CI, 1.59-2.49) than from homes with 2 married parents; and living with parents who had less than a high school education (OR, 1.44; 95% CI, 1.10-1.89) than those with at least 1 parent who had completed high school. Those whose parents had public coverage were less likely to be uninsured (OR, 0.64; 95% CI, 0.43-0.96) than were those whose parents reported private health insurance. These predictors remained significant in full-year analyses. Similar patterns of vulnerability were also found among a subset of uninsured children with privately covered parents.

CONCLUSIONS

Among all US children, more than 3% were uninsured with at least 1 insured parent. Predictors of such uninsurance included having low and middle income. Having a parent covered by only public insurance was associated with better children's coverage rates.

Uninsured but eligible children: are their parents insured? Recent findings from Oregon

BACKGROUND

Despite expansions in public health insurance programs, millions of US children lack coverage. Nearly two-thirds of Oregon's uninsured children seem to be eligible for public insurance.

OBJECTIVES

We sought to identify uninsured but eligible children and to examine how parental coverage affects children's insurance status.

METHODS

We collected primary data from families enrolled in Oregon's food stamp program, which has similar eligibility requirements to public health insurance in Oregon. In this cross-sectional, multivariable analysis, results from 2861 surveys were weighted back to a population of 84,087 with nonresponse adjustment. Key predictor variables were parental insurance status and type of insurance; the outcome variable was children's insurance status.

RESULTS

Nearly 11% of children, presumed eligible for public insurance, were uninsured. Uninsurance among children was associated with being Hispanic, having an employed parent, and higher household earnings (133-185% of the federal poverty level). Children with an uninsured parent were more likely to be uninsured, compared with those who had insured parents (adjusted odds ratio 14.21, 95% confidence interval 9.23-20.34). More surprisingly, there was a higher rate of uninsured children among privately-insured parents, compared with parents covered by public insurance (adjusted odds ratio 4.39, 95% confidence interval 2.00-9.66).

CONCLUSIONS

Low-income Oregon parents at the higher end of the public insurance income threshold and those with private insurance were having the most difficulty keeping their children insured. These findings suggest that when parents succeed in pulling themselves out of poverty and gaining employment with private health insurance coverage, children may be getting left behind.

An international perspective on worker mental health problems: who bears the burden and how are costs addressed?

OBJECTIVE

To discuss the burden of poor mental health in workers, who currently bears it, and how the associated rising costs are being addressed, from an international perspective.

METHOD

We identify the stakeholder groups and the costs they incur as a result of problems related to mental health in 6 different domains. In addition, we offer examples of programs, services, and strategies being used to either decrease costs or enhance benefits.

RESULTS

Mental illness is associated with a wide range of costs distributed across multiple stakeholders including government, employers, workers and their families, and the health care system. The costs incurred by the groups are interrelated; an attempt to decrease the burden for one group of stakeholders will inevitably affect other stakeholders. Thus the answer to the question of who bears the costs of poor mental health is "everyone."

CONCLUSIONS

Everyone could benefit from investment in improved mental health in the workplace. However, because the benefits associated with improved worker mental health are often distributed among several stakeholders, the incentives for any single stakeholder to pay for additional services for workers may be diluted. As a consequence, no one invests. Nevertheless, there is a role for all stakeholders, just as there are potential benefits for all. Along with government, employers, employees, and the health care system must invest in promoting good workplace health.