The health insurance picture in 1990

Health Insurance Mandates, Mammography, and Breast Cancer Diagnoses

We examine the effects of state health insurance mandates requiring coverage of screening mammograms. We find evidence that mammography mandates significantly increased mammography screenings by 4.5-25 percent. Effects are larger for women with less than a high school degree in states that ban deductibles, a policy similar to a provision of federal health reform that eliminates cost-sharing for preventive care. We also find that mandates increased detection of early stage in-situ pre-cancers. Finally, we find a substantial proportion of the increased screenings were attributable to mandates that are not consistent with current recommendations of the American Cancer Society.

Effects of State Cervical Cancer Insurance Mandates on Pap Test Rates

OBJECTIVE

To evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women.

DATA SOURCES

Individual-level data on 600,000 women age 19-64 from the CDC's Behavioral Risk Factor Surveillance System.

STUDY DESIGN

Twenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate.

PRINCIPAL FINDINGS

Difference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women.

CONCLUSIONS

Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.

Health care costs: on the rise again

Since 1999, health care costs have been growing faster than national income. This rapid growth has occurred as the ability of private and public purchasers to reduce service utilization and bargain for lower prices has fallen, insurers have recouped lost profits through higher premiums, and new technologies have driven up costs throughout the sector. Private insurance market responses to these rising costs may lead to reductions in the number of people with insurance and to increased fragmentation of the insurance market. Over time, technological change in medicine both increases costs and improves the quality of care. The challenge for public policy is to maintain insurance and some degree of equity in the face of these rising costs.

From physician to consumer: the effectiveness of strategies to manage health care utilization

Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.

Trends in out-of-pocket spending by insured American workers, 1990-1997

This paper examines trends in out-of-pocket spending for insured workers from 1990 to 1997. Data are from the Consumer Expenditure Survey conducted by the U.S. Bureau of Labor Statistics. The survey collects detailed quarterly data on all consumer spending from logs kept each year by more than 10,000 households with job-based health insurance. During the study period, total out-of-pocket spending in constant dollars remained unchanged. Spending for medical expenses, drugs, and supplies declined by 23 percent, but this decline was offset by rising employee contributions for health insurance premiums. The shift to managed care, whose benefit structure requires less cost sharing, may have played a role in reducing out-of-pocket spending.

Economists, public provision, and the market: changing values in policy debate

Among health services researchers, an "economizing model" of health care has eclipsed two traditional models, "social conflict" and "collective welfare." The older models emphasized social solidarity and distributive justice, but the newer one focuses on improving efficiency, minimizing risks borne by third-party payers, constraining cost increases, and improving the functioning of markets. This article examines one source of the economizing model, the work of several early and persistently prominent economists of health care, especially Mark Pauly, Martin Feldstein, and Joseph Newhouse and his colleagues at the Rand Corporation. In particular, it explores their role in transforming perceptions of health care from a set of special services into an ordinary commodity, in giving currency to apparently dispassionate as opposed to overtly value-laden analysis, and in according priority, among health services researchers and policy makers, to economists' traditional interest in fostering smoothly functioning markets. It exhibits their principal policy recommendation-income-graduate cost sharing-the sources and character of their modes of analysis, and the character of their influence on policy makers. The article concludes that the supposedly value-free economic analysis of health care rests on a cluster of values that inhibit the expression of social solidarity and the formulation of policies intended to foster distributive justice.

Ten ways HMOs have changed during the 1990s

The same forces that encouraged the expansion of managed care also brought about change in health maintenance organizations (HMOs). Using data from annual surveys of the Association of American Health Plans and other sources, this paper examines ten major changes in the HMO industry during the 1990s, including the growth of for-profit plans and the relative decline of nonprofits; the shift from vertically integrated group/staff models to virtually integrated individual practice associations/network models; industry consolidation through mergers and acquisitions; increased patient cost sharing; and the shift to capitation payment of primary care physicians. Current research is unable to show whether these changes have led to improved quality of care or patient satisfaction.

Self-insuring employee health benefits

Self-insurance is a popular way to fund employee health benefits, but it presents a potential barrier to state health insurance reform initiatives because self-insured health plans are able to avoid state regulation. Thus it is important to understand why employers self-insure. This study tests an explanatory model of self-insurance, using data from the 1989 Survey of Health Insurance Plans. Models predicting self-insurance are estimated for private employers and for all health plan sponsors, including public employers, unions, and trade associations. The author found a threshold for self-insuring among private employers at about 100 employees and another at about 200 workers when all health plan sponsors were considered. Plans with union members are more likely to be self-insured. Self-insurance is more likely in the presence of alcohol treatment mandates but less likely with mental health mandates.

Gaps in employer coverage: lack of supply or lack of demand?

According to data from the May 1988 Current Population Survey, 18 percent of workers are in firms that do not offer health insurance. The question explored here is whether the absence of insurance in these firms is related to lack of supply (that is, a failure of the firm to offer the benefit because the price it faces is too high or the benefit too low) or lack of demand (that is, employees in these firms would not purchase the insurance even if it were offered). Characteristics hypothesized to affect the supply of insurance by firms (size, rate of turnover, and union status) are found to distinguish whether or not firms offer insurance. The data show near-universal acceptance of group insurance among employees offered the opportunity to participate. Both of these factors suggest a failure of supply. However, employees in firms that do not offer insurance are young, low-wage earners who work part time. These are also characteristics of workers who do not purchase group insurance even when it is offered, suggesting that many of the workers who are not offered group insurance would not participate in a plan even if the supply failure were corrected. These findings have implications for the effectiveness of voluntary strategies to improve access, but they also raise concern over the fairness to workers of mandates requiring that they purchase coverage.

Problems with expanding Medicaid for the uninsured

Many proposals for financing health care for the uninsured recommend expanding the Medicaid program. They often advocate extending Medicaid to all those under the poverty level and standardizing program benefits. However, the proposals have ignored important problems that must be resolved if the plans are to be successfully implemented, the most serious being the fiscal impacts that such proposals would have on states. The current Medicaid matching formula fails to reflect either the size of a state's Medicaid program or its ability to pay for it. As a result, the proportional fiscal effort that expansion proposals would require of states would greatly exceed that required of the federal government. Additionally, the fiscal impact would vary widely and have little relationship to a state's current Medicaid program generosity. Besides fiscal problems, significant differences exist between Medicaid and private plans in the areas of benefits, cost sharing, managed care, cost containment, and provider payment. Under a national system of health care, these differences would limit program economies, and create problems with perceived equity, continuity of care, and migration effects.

US health care. III: The reform problem

Images

Employer-sponsored health insurance in 1991

Since 1987 the Health Insurance Association of America (HIAA) has documented features of employer-sponsored group health insurance through detailed surveys of over 3,000 U.S. firms. The 1991 employer survey reveals several noteworthy developments. The percentage of small firms (100 employees and under) that offer health insurance to their employees has declined since 1989. With a significant increase in health maintenance organization (HMO) market share, more than half (54 percent) of employees in employer-sponsored plans are now covered by managed care plans. Premiums increased 14 percent in 1991, showing identical increases for conventional, HMO, and preferred provider organization (PPO) plans. The percentage of employees in self-insured health plans decreased from 45 percent in 1990 to 40 percent in 1991.