Measuring adequacy of coverage for the privately insured: new state estimates to monitor trends in health insurance coverage

The financial burden of out-of-pocket expenses in the United States and Canada: How different is the United States?

BACKGROUND

This article compares the burden that medical cost-sharing requirements place on households in the United States and Canada. It estimates the probability that individuals with similar demographic features in the two countries have large medical expenses relative to income.

METHOD

The study uses 2010 nationally representative household survey data harmonized for cross-national comparisons to identify individuals with high medical expenses relative to income. Using logistic regression, it estimates the probability of high expenses occurring among 10 different demographic groups in the two countries.

RESULTS

The results show the risk of large medical expenses in the United States is 1.5-4 times higher than it is in Canada, depending on the demographic group and spending threshold used. The United States compares least favorably when evaluating poorer citizens and when using a higher spending threshold.

CONCLUSION

Recent health care reforms can be expected to reduce Americans' catastrophic health expenses, but it will take very large reductions in out-of-pocket expenditures-larger than can be expected-if poorer and middle-class families are to have the financial protection from high health care costs that their counterparts in Canada have.

Prevalence and predictors of underinsurance among low-income adults

BACKGROUND

Millions of adults will gain Medicaid or private insurance in 2014 under the Affordable Care Act, and prior research shows that underinsurance is common among middle-income adults. Less is known about underinsurance among low-income adults, particularly those with public insurance.

OBJECTIVE

To compare rates of underinsurance among low-income adults with private versus public insurance, and to identify predictors of being underinsured.

DESIGN

Descriptive and multivariate analysis of data from the 2005-2008 Medical Expenditure Panel Survey.

PARTICIPANTS

Adults 19-64 years of age with family income less than 125 % of the Federal Poverty Level (FPL) and full-year continuous coverage in one of four mutually exclusive insurance categories (N = 5,739): private insurance, Medicaid, Medicare, and combined Medicaid/Medicare coverage.

MAIN MEASURES

Prevalence of underinsurance among low-income adults, defined as out-of-pocket expenditures greater than 5 % of household income, delays/failure to obtain necessary medical care due to cost, or delays/failure to obtain necessary prescription medications due to cost.

KEY RESULTS

Criteria for underinsurance were met by 34.5 % of low-income adults. Unadjusted rates of underinsurance were 37.7 % in private coverage, 26.0 % in Medicaid, 65.1 % in Medicare, and 45.1 % among Medicaid/Medicare dual enrollees. Among underinsured adults, household income averaged $6,181 and out-of-pocket spending averaged $1,115. Due to cost, 8.1 % and 12.8 % deferred or delayed obtaining medical care or prescription medications, respectively. Predictors of underinsurance included being White, unemployed, and in poor health. After multivariate adjustment, Medicaid recipients were significantly less likely to be underinsured than privately insured adults (OR 0.22, 95 % CI 0.17-0.28).

CONCLUSIONS

Greater than one-third of low-income adults nationally were underinsured. Medicaid recipients were less likely to be underinsured than privately insured adults, indicating potential benefits of expanded Medicaid under health care reform. Nonetheless, more than one-quarter of Medicaid recipients were underinsured, highlighting the importance of addressing cost-related barriers to care even among those with public coverage.

The mission of safety net organizations following national insurance reform

National health insurance reform will pose considerable challenges to the core missions of safety net organizations that serve the uninsured. Those who currently donate money or time will, rightly or wrongly, view uninsured recipients as less deserving on the whole. Nevertheless, safety net organizations can serve several critical functions that continue to justify their existence and support.One important mission is to maintain access for low-income uninsured until all elements of insurance reform are fully in place. Second, once the reform is implemented, people will need a great deal of assistance and encouragement to determine what they are supposed to do and where they are supposed to sign up. Third, substantial portions of the remaining uninsured will continue to lack affordable insurance options, and large numbers of people eligible for coverage will unavoidably undergo temporary gaps in coverage as their family and financial circumstances change. Finally, not all people with insurance will have affordable access to all needed care. Market conditions will continue pushing higher levels of patient cost-sharing through deductibles and co-payments.To serve these multiple needs, safety net organizations should consider adapting their missions and business models so that they accept both insured and uninsured patients under a sliding fee scale that varies charges according to ability to pay.