More offers, fewer takers for employment-based health insurance: 1987 and 1996

Children and Managed Care: What Research can, can’t, and Should Tell Us about Impact

The speed and ubiquity of the move from fee-for-service to managed care raises questions about how these changes affect children. This article examines (1) the pace and context of the move to managed care for children, (2) potential opportunities and challenges emerging from these changes, (3) research findings on how managed care affects children, and (4) next steps for learning more. The research review provides a consistent answer to whether managed care is good for children: it depends on what kind of managed care, which children, and under what circumstances. This finding suggests lessons for future research: (1) focus on particular features of managed care, (2) get inside the “black box” of managed care and examine providers, (3) expand the portfolio of research on children: research on adults cannot “trickle down” to children, (4) foster research partnerships and networks, and (5) focus on poor and chronically ill children.

Changes in Cigarette Smoking Behavior Among US Young Workers From 2005 to 2010: The Role of Occupation

INTRODUCTION

Young adult workers (18-24 years) in the United States have been identified as a high-risk group for smoking. This study compares changes in smoking behavior by occupational class among this group between 2005 and 2010.

METHODS

Data were pooled from the Tobacco Supplement in the 2005 and 2010 National Health Interview Survey. All respondents 18-24 years who reported that they were employed during the two surveys were selected (n = 1880 in 2005; and n = 1531 in 2010). Weighted percentages and 95% confidence interval were reported. Logistic regression analyses were performed to compare smoking behavior between occupational groups (white-collar, blue-collar, and service) and between years (2005-2010), and to examine correlates of smoking, successful quit attempt, and heavy smoking.

RESULTS

Smoking prevalence and daily smoking declined in 2010 in white-collar. Smoking prevalence and intensity decreased while age of smoking initiation increased in blue-collar workers. Young workers were more likely to smoke in 2005 than 2010. Service and blue-collar workers were more likely to smoke than white-collar workers. Older young adults, whites, individuals with a high school/or less education, those without health insurance were more likely to smoke. White workers and individuals with a high school/or less education were more likely to be heavy smokers.

CONCLUSIONS

White-collar workers have benefited the most from tobacco control efforts. Although improvements were seen in smoking behavior among blue-collar workers, smoking prevalence remained the highest in this group. Smoking behavior among service workers did not change. Young service workers and blue-collar are priority populations for workplace tobacco control efforts.

IMPLICATIONS

The current study examines changes in smoking behavior among young adult workers (18-24 years) by occupational class (white-collar, blue-collar, and service workers) between 2005 and 2010. Data were pooled from the Tobacco Supplement in the 2005 and 2010 National Health Interview Survey. Smoking prevalence and daily smoking declined significantly in white-collar workers. No change in smoking behavior was observed among service workers. Positive changes in smoking behavior were observed among blue-collar workers, but smoking prevalence remained the highest in this group. Blue-collar and service workers are priority groups for future workplace tobacco control efforts.

The Take-Up of Employer-Sponsored Insurance Among Americans with Mental Disorders: Implications for Health Care Reform

Little is known about how take-up of private health insurance coverage differs between those with and without mental disorders. This study seeks to fill this gap by using data from the 2004-2008 Medical Expenditure Panel Survey to examine differences in offers and take-up of employer-sponsored insurance (ESI) among adults aged 27-54. Little evidence that mental disorders are associated with take-up of offers of ESI coverage was found. This suggests that take-up rates in the Affordable Care Act (ACA) marketplaces by those with and without mental disorders may be similar. The ACA is especially important to Americans with mental disorders, many of whom lack access to ESI coverage to pay for mental health treatment either through their own job or through a spouse's job.

Declines in employer-sponsored insurance between 2000 and 2008: examining the components of coverage by firm size

OBJECTIVE

To examine trends in employer-sponsored health insurance coverage rates and its associated components between 2000 and 2008, to provide a baseline for later evaluations of the Affordable Care Act, and to provide information to policy makers as they design the implementation details of the law.

DATA SOURCES

Private sector employer data from the 2000, 2001, and 2008 Medical Expenditure Panel Survey-Insurance Component (MEPS-IC).

STUDY DESIGN

We examine time trends in employer offer, eligibility, and take-up rates. We add a new dimension to the literature by examining dependent coverage and decomposing its trends. We investigate heterogeneity in trends by firm size.

DATA COLLECTION

The MEPS-IC is an annual survey, sponsored by the Agency for Healthcare Research and Quality and conducted by the U.S. Census Bureau. The MEPS-IC obtains information on establishment characteristics, whether an establishment offers health insurance, and details on up to four plans.

PRINCIPAL FINDINGS

We find that coverage rates for workers declined in both small and large firms. In small firms, coverage declined due to a drop in both offer and take-up rates. In the largest firms, offer rates were stable and the decline was due to falling take-up rates. In addition, enrollment shifted toward single coverage and away from dependent coverage in both small and large firms. For small firms, this shift was due to declining offer and take-up rates for dependent coverage. In large firms, offers of dependent coverage were stable but take-up rates dropped. Within the category of dependent coverage, the availability of employee-plus-one plans increased in all firm size categories, but take-up rates for these plans declined in small firms.

Age and the purchase of prescription drug insurance by older adults

The Medicare Part D Prescription Drug Program places an unprecedented degree of choice in the hands of older adults despite concerns over their ability to make effective decisions and desire to have extensive choice in this context. While previous research has compared older adults to younger adults along these dimensions, our study, in contrast, examines how likelihood to delay decision making and preferences for choice differ by age among older age cohorts. Our analysis is based on responses of older adults to a simulation of enrollment in Medicare Part D. We examine how age, numeracy, cognitive reflection, and the interaction between age and performance on these instruments are related to the decision to enroll in a Medicare prescription drug plan and preference for choice in this context. We find that numeracy and cognitive reflection are positively associated with enrollment likelihood and that they are more important determinants of enrollment than age. We also find that greater numeracy is associated with a lower willingness to pay for choice. Hence, our findings raise concern that older adults, and, in particular, those with poorer numerical processing skills, may need extra support in enrolling in the program: they are less likely to enroll than those with stronger numerical processing skills, even though they show greater willingness to pay for choice.

The persistent gap in health-care coverage between low- and high-income workers in Washington State: BRFSS, 2003-2007

OBJECTIVES

We examined the disparities in health-care coverage between low- and high-income workers in Washington State (WA) to provide support for possible policy decisions for uninsured workers.

METHODS

We examined data from the WA Behavioral Risk Factor Surveillance System 2003-2007 and compared workers aged 18-64 years of low income (annual household income <$35,000) and high income (annual household income ≥$35,000) on proportions and sources of health-care coverage. We conducted multivariable logistic regression analyses on factors that were associated with the uninsured.

RESULTS

Of the 54,536 survey respondents who were working-age adults in WA, 13,922 (25.5%) were low-income workers. The proportions of uninsured were 38.2% for low-income workers and 6.3% for high-income workers. While employment-based health benefits remained a dominant source of health insurance coverage, they covered only 40.2% of low-income workers relative to 81.5% of high-income workers. Besides income, workers were more likely to be uninsured if they were younger; male; Hispanic; less educated; not married; current smokers; self-employed; or employed in agriculture/forestry/fisheries, construction, and retail. More low-income workers (28.7%) reported cost as an issue in paying for health services than did their high-income counterparts (6.7%).

CONCLUSION

A persistent gap in health-care coverage exists between low- and high-income workers. The identified characteristics of these workers can be used to implement policies to expand health insurance coverage.

Small group employer participation in New Mexico's State Coverage Insurance program: lessons for federal reform

OBJECTIVE

To identify factors associated with small group employer participation in New Mexico's State Coverage Insurance (SCI) program.

DATA SOURCES

Telephone surveys of employers participating in SCI (N=269) and small employers who inquired about SCI (N=148) were fielded September 2008-January 2009.

STUDY DESIGN

Descriptive and multivariate analyses investigated differences between employer samples, including employer characteristics, concerns that applied to the business when deciding whether to participate in SCI, prior offerings of insurance to workers, and perceived affordability of the program.

DATA COLLECTION/EXTRACTION METHODS

Unweighted employer samples yielded 88 and 75 percent response rates for the participating and inquiring employers, respectively.

PRINCIPAL FINDINGS

The administrative issue most commonly selected by inquiring employers as applying to their business was difficulty understanding how eligibility requirements applied to their business and its employees (53.5 percent). Inquiring businesses were significantly more likely to report concern about affording to pay the premiums in the first month (35.6 versus 18.7 percent) and the cost to the business over the long run (46.5 versus 26.6 percent) relative to participating employers. From the model results, businesses with the fewest full-time employees (zero to two) were 19 percentage points less likely to participate relative to businesses with six or more full-time employees.

CONCLUSIONS

Administrative and cost barriers to participation in SCI reported by employers suggest that the tax credit offered to small businesses under new federal provisions, which merely offsets the employer portion of premium, could be more effective if accompanied by additional supports to businesses.

Workers on the margin: who drops health coverage when prices rise?

We revisit the question of price elasticity of employer-sponsored insurance (ESI) take-up by directly examining changes in the take-up of ESI at a large firm in response to exogenous changes in employee premium contributions. We find that, on average, a 10% increase in the employee's out-of-pocket premium increases the probability of dropping coverage by approximately 1%. More importantly, we find heterogeneous impacts: married workers are much more price-sensitive than single employees, and lower-paid workers are disproportionately more likely to drop coverage than higher-paid workers. Elasticity estimates for employees below the 25th percentile of salary distribution in our sample are nearly twice the average.

The enigma of higher income immigrants with lower rates of health insurance coverage in the United States

This research compares rates of health insurance coverage among middle-class non-elderly immigrants to native-born American adults using data from the March 1996-2000 Supplements to the Current Population Survey. Probit regressions reveal that immigrants were three times as likely to be uninsured at income levels exceeding $50,000, controlling for economic, demographic and immigrant-related characteristics. Work-related characteristics, income, martial status and nativity considerably influenced health insurance status for all adults, but work-related factors had the strongest effect on immigrants' rates of coverage. Why, ceteris paribus, immigrants have lower coverage rates is unclear. Many low-income and recent immigrants face barriers to access due to legal status or job sector. But lower rates of health insurance coverage which persist among long-time residents at higher income levels cannot be explained by such barriers, a finding highly relevant for policy makers. Encouraging uninsured immigrants to opt into health plans voluntarily will remain a challenge.

Employer-sponsored health insurance and the promise of health insurance reform

The central role that employers play in financing health care is a distinctive feature of the U.S. health care system, and the provision of health insurance through the workplace has important implications well beyond its role as a source of health care financing. In this paper, we consider the "goodness of fit" of employer-sponsored health insurance (ESI) in the current economic and health insurance environments and in light of prospects for a vigorous national debate over the shape of health care reform. The main issue that we explore is whether ESI can have a viable role in health system reform efforts or whether such coverage will need to be significantly modified or even abandoned as reform seeks to address important issues in the efficient provision and equitable distribution of health insurance coverage.

Effects of immigration on the health insurance status of natives

The objective of the paper is to estimate the effects of immigration on natives' probability of having private coverage and being uninsured. To examine whether immigrants affected employers' decisions to offer health benefits the study estimates immigration effects on natives' probability of being offered, eligible for, and a policy-holder of health insurance. Although in many cases the effects are statistically significant, most effects are very small. The increase in immigrant labor supply from 1995 to 2005 increases natives' uninsurance rates by about 0.7 percentage points and reduces the natives' probability of being offered and a holder of coverage by 0.8 and 1.9 percentage points, respectively. Immigrants' weaker preferences for coverage relative to natives' may be the key factor in this result.

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 vs. Insured Population

This study identified the underlying demographic and socioeconomic factors associated with insurance status among nonelderly Americans (age 19-64), as well as compared health care utilization between insured and uninsured. Data from the Community Tracking Study 1996-1997 Household Survey were analyzed. Approximately 74 percent of uninsured Americans are nonelderly Americans. Among the nonelderly Americans, about 17 percent are uninsured. Our findings show that insurance status varies significantly by region, age, race, gender, marital status, income, education, employment status, and health status. Also, the insured nonelderly Americans were found to have better access to health care than the uninsured nonelderly.

Women's health insurance coverage 1980-2005

BACKGROUND

In the fragmented US health insurance system, women's health insurance coverage is an outcome both of changes in the availability of private and public health insurance and of changing patterns of labor force participation and household formation. Over the past 2 decades, women's socioeconomic circumstances have changed and public policy around health insurance coverage for low-income women has also undergone substantial modification.

METHODS

This study examines the roles of these changes in circumstances and policy on the level and composition of women's health insurance. Using the Census Bureau's March Current Population Survey 1980-2005, the government's principal source of nationally representative labor market and health insurance data, we examine how changes in marriage, full-time and part-time labor force participation, and public policy around coverage affected the level and source of women's health insurance coverage over 3 periods: 1980-1987, 1988-1994, and 1995-2005.

RESULTS

Health insurance coverage rates have fallen for both women and men since 1980. What makes women different is that, in addition to the decline in coverage, the composition of health insurance coverage for women has also changed markedly. More women now obtain health insurance on their own, rather than as dependents, than did in 1980. A larger fraction of insured women are now enrolled in Medicaid than were in 1980. Women's routes to coverage have changed as their social and economic circumstances have changed and as policy, especially Medicaid policy, has evolved.

CONCLUSIONS

Women's channels for obtaining health insurance coverage are more fragmented than those of men. The availability of multiple sources of coverage, and the possibility of moving amongst them, have not, however, insulated women from the overall declines in health insurance coverage caused by the rising cost of private health insurance.

Pathways to coverage: the changing roles of public and private sources

Using data from the Medical Expenditure Panel Surveys for 1997 and 2005, spanning the eight-year period after enactment of the State Children's Health Insurance Program (SCHIP), we examine whether the composition of insurance coverage has changed for working families. Public coverage has played an increasingly important role for working families with children. For families without access to job-based insurance, roughly two-thirds of single-parent and over half of two-parent families with children had at least one family member covered by public insurance in 2005. Among families with access to job-based insurance, nearly half of minority single-parent families had at least one family member with public coverage.

Estimating workers' marginal valuation of employer health benefits: would insured workers prefer more health insurance or higher wages?

In recent years the cost of health insurance has been increasing much faster than wages. In the face of these rising costs, many employers will have to make difficult decisions about whether to cut back health benefits or to compensate workers with lower wages or lower wage growth. In this paper, we ask the question, "Which do workers value more -- one additional dollar's worth of health benefits or one more dollar in their pockets?" Using a new approach to obtaining estimates of insured workers' marginal valuation of health benefits this paper estimates how much, on average, employees value the marginal dollar paid by employers for their workers' health insurance. We find that insured workers value the marginal health premium dollar at significantly less than the marginal wage dollar. However, workers value insurance generosity very highly. The marginal dollar spent on health insurance that adds an additional dollar's worth of observable dimensions of plan generosity, such as lower deductibles or coverage of additional services, is valued at significantly more than one dollar.

The relative importance of worker, firm, and market characteristics for racial/ethnic disparities in employer-sponsored health Insurance

The characteristics of an individual, the local labor market, and the firm where an individual is employed each may be associated with racial and ethnic disparities in employer-sponsored insurance (ESI). This study estimates two models to determine the relative effects of each of these three sets of characteristics on the likelihood a worker has a job with ESI. One model has two outcomes: the job comes with ESI or not. The other model has five possible outcomes: the individual is not offered ESI and is uninsured, the individual is not offered ESI and is insured; the individual is offered ESI but turns it down and is uninsured; the individual is offered ESI but turns it down and is insured; and the individual is offered ESI and accepts. Findings indicate that individual characteristics and firm characteristics are more likely to have significant and substantial effects on the probability that a person has ESI, while the effects of market characteristics appear to be conveyed through firm characteristics. Being African American or Hispanic is not significantly associated with having ESI in the two-outcomes model, but in the five-outcomes model each is associated significantly with being uninsured, either because the person has not been offered ESI or has declined offered coverage. Clearly, examining more nuanced outcomes is more informative about the role of race and ethnicity in why working people are uninsured.

Immigrants and employer-sponsored health insurance

OBJECTIVE

To investigate the factors underlying the lower rate of employer-sponsored health insurance coverage for foreign-born workers.

DATA SOURCES

2001 Survey of Income and Program Participation.

STUDY DESIGN

We estimate probit regressions to determine the effect of immigrant status on employer-sponsored health insurance coverage, including the probabilities of working for a firm that offers coverage, being eligible for coverage, and taking up coverage.

DATA EXTRACTION METHODS

We identified native born citizens, naturalized citizens, and noncitizen residents between the ages of 18 and 65, in the year 2002.

PRINCIPAL FINDINGS

First, we find that the large difference in coverage rates for immigrants and native-born Americans is driven by the very low rates of coverage for noncitizen immigrants. Differences between native-born and naturalized citizens are quite small and for some outcomes are statistically insignificant when we control for observable characteristics. Second, our results indicate that the gap between natives and noncitizens is explained mainly by differences in the probability of working for a firm that offers insurance. Conditional on working for such a firm, noncitizens are only slightly less likely to be eligible for coverage and, when eligible, are only slightly less likely to take up coverage. Third, roughly two-thirds of the native/noncitizen gap in coverage overall and in the probability of working for an insurance-providing employer is explained by characteristics of the individual and differences in the types of jobs they hold.

CONCLUSIONS

The substantially higher rate of uninsurance among immigrants is driven by the lower rate of health insurance offers by the employers of immigrants.

Individual health insurance within the family: can subsidies promote family coverage?

This paper examines the role of price in health insurance coverage decisions within the family to guide policy in promoting whole family coverage. We analyze the factors that affect individual health insurance coverage among families, and explore family decisions about whom to cover and whom to leave uninsured. The analysis uses household data from California combined with abstracted individual health plan benefit and premium data. We find that premium subsidies for individual insurance would increase family coverage; however, their effect likely would be small relative to their implementation cost.

Why are Latinos the most uninsured racial/ethnic group of US children? A community-based study of risk factors for and consequences of being an uninsured Latino child

BACKGROUND

Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children.

OBJECTIVE

[corrected] The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children.

METHODS

A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance.

RESULTS

Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers.

CONCLUSIONS

After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

Workers Who Decline Employment-Related Health Insurance

BACKGROUND

Families of workers who decline coverage represent a substantial share of the uninsured and publicly-insured population in the United States.

OBJECTIVE

We examined health status, access to health care, utilization, and expenditures among families that declined health insurance coverage offered by employers using data from the Medical Expenditure Panel Survey for 2001 and 2002.

RESULTS

We found differences in insurance status for adults and children among families with offers. We found that among low-income families with offers, children are less likely to have private insurance compared with adults. However, the majority of children who decline private insurance end up with public coverage, whereas most of adults who decline offers remain uninsured. Decliners are more likely to report poor health, yet they are also less likely to have high cost medical conditions. Families declining coverage have weaker preferences for insurance than families that take up. Although access to care is lower among the decliners who remain uninsured, decliners with public insurance have similar access to care as those with private insurance. Families turning down coverage are more likely to face high expenditure burdens as a percentage of income and more likely to have financial barriers to care. Families who decline coverage rely heavily on the safety net. Public sources and uncompensated care account for 72% of total expenditures among adults who decline coverage.

CONCLUSIONS

Our results suggest that policy initiatives aimed at increasing take up among workers need to take into account the incentives workers face given the availability of care through public sources and uncompensated care.

Health insurance coverage for vulnerable populations: contrasting Asian Americans and Latinos in the United States

This paper examines the role that population vulnerabilities play in insurance coverage for a representative sample of Latinos and Asians in the United States. Using data from the National Latino and Asian American Study (NLAAS), these analyses compare coverage differences among and within ethnic subgroups, across states and regions, among types of occupations, and among those with or without English language proficiency. Extensive differences exist in coverage between Latinos and Asians, with Latinos more likely to be uninsured. Potential explanations include the type of occupations available to Latinos and Asians, reforms in immigration laws, length of time in the United States, and regional differences in safety-net coverage. Policy implications are discussed.

Employer health insurance offerings and employee enrollment decisions

OBJECTIVE

To determine how the characteristics of the health benefits offered by employers affect worker insurance coverage decisions.

DATA SOURCES

The 1996-1997 and the 1998-1999 rounds of the nationally representative Community Tracking Study Household Survey.

STUDY DESIGN

We use multinomial logistic regression to analyze the choice between own-employer coverage, alternative source coverage, and no coverage among employees offered health insurance by their employer. The key explanatory variables are the types of health plans offered and the net premium offered. The models include controls for personal, health plan, and job characteristics.

PRINCIPAL FINDINGS

When an employer offers only a health maintenance organization married employees are more likely to decline coverage from their employer and take-up another offer (odds ratio (OR)=1.27, p<.001), while singles are more likely to accept the coverage offered by their employer and less likely to be uninsured (OR=0.650, p<.001). Higher net premiums increase the odds of declining the coverage offered by an employer and remaining uninsured for both married (OR=1.023, p<.01) and single (OR=1.035, p<.001) workers.

CONCLUSIONS

The type of health plan coverage an employer offers affects whether its employees take-up insurance, but has a smaller effect on overall coverage rates for workers and their families because of the availability of alternative sources of coverage. Relative to offering only a non-HMO plan, employers offering only an HMO may reduce take-up among those with alternative sources of coverage, but increase take-up among those who would otherwise go uninsured. By modeling the possibility of take-up through the health insurance offers from the employer of the spouse, the decline in coverage rates from higher net premiums is less than previous estimates.

The demand for dependent health insurance: how important is the cost of family coverage?

From the mid-1980s to the mid-1990s, the proportion of non-elderly Americans with employment-based health insurance declined. Roughly 80% of this decline was due to the loss of coverage by dependent family members. During this period, workers became increasingly responsible for the costs of family coverage, while expanded Medicaid coverage provided low-income working families with an alternative to employment-based insurance. We examine the role of out-of-pocket premiums and expanded Medicaid eligibility in households' demand for employment-based family coverage. Cross-sectional results reveal that demand is affected by both factors. We find that between 1987 and 1996, the increase in out-of-pocket premium costs accounted for nearly half of the decline in dependent coverage while expanded Medicaid eligibility represented 14% of the decline.

Uninsured working immigrants: a view from a California county

We inform a county's efforts to provide health insurance to uninsured working immigrants-a group left out of national and state strategies that aim to expand coverage. We analyzed a population-based survey data administered in English, Spanish, Cantonese, Mandarin, Korean, Vietnamese, and Dari on 5,540 nonelderly adult workers in Alameda County, California. The study models the likelihood of employment-based coverage, estimates the eligibility for public programs, and evaluates the affordability of average employee share of premiums by citizenship status and years lived in the United States (tenure). Immigrant workers in Alameda County are disproportionately uninsured. They constitute 29% of the employee labor force but 54% of uninsured employees. Employment-based coverage increased with citizenship and length of stay (tenure) in the United States. Noncitizens with less than 5 years residency in the United States faced the greatest disadvantage in securing employment-based coverage, an effect that is greater than disadvantages associated with race/ethnicity. A citizenship-tenure divide existed in obtaining employment-based coverage, suggesting that policies focusing on noncitizen and new immigrant workers would greatly relieve the disparate uninsured rates among workers. The expansion of nonemployment-based coverage programs would cover more than 30% of Alameda County's uninsured immigrant workers; but subsidies will also be needed for the lowest-income workers who are not eligible for these programs.

Subsidies to employee health insurance premiums and the health insurance market

One approach to covering the uninsured that is frequently advocated by policy-makers is subsidizing the employee portion of employer-provided health insurance premiums. But, since the vast majority of those offered employer-provided health insurance already take it up, such an approach is only appealing if there is a very high takeup elasticity among those who are offered and uninsured. Moreover, if plan choice decisions are price elastic, then such subsidies can at the same time increase health care costs by inducing selection of more expensive plans. We study an excellent example of such subsidies: the introduction of pre-tax premiums for postal employees in 1994, and then for the remaining federal employees in 2000. We do so using a census of personnel records for all federal employees from 1991 through 2002. We find that there is a very small elasticity of insurance takeup with respect to its after-tax price, and a modest elasticity of plan choice. Our results suggest that the federal government did little to improve insurance coverage, but much to increase health care expenditures, through this policy change.

The effect of the availability of charity care to the uninsured on the demand for private health insurance

The economic reasons why some people do not obtain health insurance are unclear. In this paper, I test the hypothesis that the availability of charity care to the uninsured reduces the likelihood of obtaining private coverage. I utilize variation in the availability of charity care across the different markets in the Community Tracking Study's Household Survey (CTS-HS) using an "access to care" measure of the uninsured's cost-related difficulties in obtaining medical care, to both aggregate across the various "safety net" providers and control for its potentially endogenous supply. I find evidence supporting this hypothesis for low-income people, in both the individual market and the employment-based group market. I also estimate a joint model of offer and take-up decisions for the group market sample and find that the availability of charity care reduces low-income workers' offer rates but not their take-up rates.

Low-Income workers with employer-sponsored insurance: who's at risk when employer coverage is no longer an option?

A firm's decision to drop the offer of employer-sponsored insurance (ESI), reduce eligibility for ESI, or significantly increase employee costs would have serious implications for the health insurance status of currently covered low-income workers. The authors find that at least a third of currently covered low-income workers do not have affordable insurance options outside of the group market. Furthermore, a simulation analysis shows that 54 percent of those workers would become uninsured if their employers were to drop ESI. This would result in an additional 1 million uninsured adults if 10 percent of low-income workers lost their ESI offer, and at least 350,000 uninsured adults if 10 percent of workers in firms with fewer than 100 employees (the firms most likely to drop coverage) lost their ESI. The authors also find that expanding public programs to cover low-income workers would reduce the high uninsurance rate by half, but substantial minorities would remain uninsured.

Rural-Urban Differences in Employment-Related Health Insurance

CONTEXT

Rural residents are disproportionately represented among the uninsured in the United States.

PURPOSE

We compared nonelderly adult residents in 3 types of nonmetropolitan areas with metropolitan workers to evaluate which characteristics contribute to lack of employment-related insurance. RESEARCH DESIGN AND ANALYSIS: Data were obtained from the Medical Expenditure Panel Survey, pooled across 3 panels (1996--1998) to enhance the rural sample size. Econometric decomposition was used to quantify the contribution of employment structure to differences in the probability of being offered employment-related health insurance.

FINDINGS

The most rural workers are 10.4 percentage points less likely to be offered insurance compared with urban workers; the difference is smaller for residents of other rural areas. In rural counties not adjacent to urban areas, lower wages and smaller employers each account for about one-third of the total difference.

CONCLUSIONS

Health insurance disparities associated with rural residence are related to the structure of employment. Major factors include smaller employers, lower wages, greater prevalence of self-employment, and sociodemographic characteristics.

The effect of premiums on the decision to participate in health insurance and other fringe benefits offered by the employer: evidence from a real-world experiment

In this paper, we investigate the effect of the out-of-pocket premium on the decision to enroll in employer health insurance and other benefits plans including dental insurance, vision care, long-term care insurance, and wellness benefits. Previous estimates of the effects of premium on takeup of health insurance could be biased toward zero due to a correlation between premium and unobservable demand or plan quality. We solve this problem using data representing hypothetical choices by employees under three different price regimes, providing price variation uncorrelated with either individual-specific or plan-specific unobservables. We find that workers are insensitive to price in health insurance takeup. Workers show much greater price sensitivity to decisions about dental insurance, vision plans, long-term care insurance, and wellness benefits. We conclude that premium subsidies are unlikely to have a substantial impact on increasing insurance rates of workers already offered employer insurance.

The impact of states' small group health insurance reforms on uninsurance rates

The impact of states' small group market reforms on uninsurance rates was examined. Reform status was quantified on five reform dimensions: Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. These reform indices were calculated based on actuarial judgment of the market impact potential of each regulation. Regression analysis showed no association between uninsurance rates and the depth of reforms on any dimension, while controlling for income, foreign-born population, black population, and employment in the smallest businesses. Possible reasons for the lack of impact are discussed.

Reducing the Numbers of the Uninsured

The objective of the study described in this article was to identify a model that best predicts state uninsurance rates and quantifies the contribution of socio-economic factors to enable targeted state programs to reduce uninsurance. Linear regression analysis was carried out using state uninsurance rate as the dependent variable and state-level data on demographic, employment, income, and health care environment data (independent variables). For 2000 data, the model R is 0.77, indicating that 77% of the variation in uninsurance rates is explained by the percentage of immigrant population, the workforce in very small businesses, the Black population, the state's median income, and the Medicare-aged population (model R = 0.77 for 1999 and 0.68 for 1998 data). A 1% increase in immigrant population is associated with 0.18% increase in uninsurance rate. A 1% increase in workforce employed in very small businesses associates with 0.79% increase in uninsurance. The findings indicate substantial potential for reducing uninsurance through targeted state policies. Policy recommendations are made to alleviate the insurance hurdles faced by immigrant and small business employee populations.

Children's health coverage: a quarter-century of change

Data from a series of medical spending surveys over the past twenty-five years show that uninsurance rates for children have fallen to levels not seen since the late 1970s (about 8 percent). Rates of uninsurance have fallen in particular for poor children. Deteriorating family economic circumstances, along with a weakened safety net, contributed to the decrease of private insurance coverage and rising uninsurance rates between 1977 and 1987. Although family circumstances have stabilized since the late 1980s, high annual increases in health insurance costs have continued to erode private coverage. Public coverage expansions have reversed the surge in uninsurance rates during 1977-1987.

State trends in uninsurance among individuals aged 18 to 64 years: United States, 1992-2001

OBJECTIVES

We analyzed state-specific uninsurance trends among US adults aged 18 to 64 years.

METHODS

We used logistic regression models to examine Behavioral Risk Factor Surveillance System data for uninsurance from 1992 to 2001 in 47 states.

RESULTS

Overall, uninsurance rates increased in 35 states and remained unchanged in 12 states. Increases were observed among people aged 30 to 49 years (in 34 states) and 50 to 64 years (in 24 states), and increases were also observed among individuals at middle and low income levels (in 39 states and 19 states, respectively), individuals employed for wages (in 33 states), and the self-employed (in 18 states).

CONCLUSIONS

Among adults aged 18-64, rates of uninsurance increased in most states from 1992 through 2001. Decreased availability of employer-sponsored health insurance, rising health care costs, and state fiscal crises are likely to worsen the growing uninsurance problem.

Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population

BACKGROUND

Hispanic Americans are often treated as a monolithic ethnic group with a single pattern of healthcare utilization. However, there could be considerable differences within this population. We examine the association between use of healthcare services and Hispanic Americans'country of ancestry or origin, language of interview, and length of time lived in the United States.

METHODS

Our data come from the Medical Expenditure Panel Survey, a nationally representative survey of healthcare use and expenditures. Descriptive statistics and logistic regression results are presented.

RESULTS

Multivariate models show that Mexicans and Cubans are less likely, and Puerto Ricans more likely, to have any emergency department visits than non-Hispanic whites. Mexicans, Central American/Caribbeans, and South Americans are less likely to have any prescription medications. All Hispanics are less likely to have any ambulatory visits and prescription medications, whereas only those with a Spanish-language interview are less likely to have emergency department visits and inpatient admissions. More recent immigrants are less likely to have any ambulatory care or emergency department visits, whereas all Hispanics born outside the United States are less likely to have any prescription medications.

CONCLUSIONS

The Hispanic population is composed of many different groups with diverse health needs and different barriers to accessing care. Misconceptions of Hispanics as a monolithic population lacking within-group diversity could function as a barrier to efforts aimed at providing appropriate care to Hispanic persons and could be 1 factor contributing to inequalities in the availability, use, and quality of healthcare services in this population.

The Impact Of The ‘Aging Of America’ On Children

The continued demographic trend of the "aging of America" has many implications for U.S. society. Although their population has remained relatively constant, children are becoming a smaller proportion of the overall population. The rapidly changing age-related U.S. demographics raises issues we have not yet chosen to address. These changes have important implications for children and will become manifest in the financing of both public programs and private markets for health, education, and social services, whether or not specific political actions are taken. Investment in children's health can affect the health and productivity of the next generation of Americans.

Worker decisions to purchase health insurance

Studying worker health insurance choices is usually limited by the absence of price data for workers who decline their employer's offer. This paper uses a new Medical Expenditure Panel Survey file which links household and employer survey respondents, supplying data for both employer insurance takers and declines. We test for whether out-of-pocket or total premium better explains worker behavior, estimate price elasticities with observed prices and with imputed prices, and test for worker sorting among jobs with and without health insurance. We find that out-of-pocket price dominates, that there is some upward bias from estimating elasticities with imputed premiums rather than observed premiums, and that workers do sort among jobs but this does not affect elasticity estimates appreciably. Like earlier studies with less representative worker samples, we find worker price elasticity of demand to be quite low. This suggests that any premium subsidies must be large to elicit much change in worker take-up behavior.

Employer offers, private coverage, and the tax subsidy for health insurance: 1987 and 1996

Economists have long been interested in the effect of tax-based subsidies on private health insurance coverage. We examine this relationship using pooled data from the 1987 National Medical Expenditure Survey and the 1996 Medical Expenditure Panel Survey. Our main tax price elasticity estimates for employer offers and for private coverage are near the mid-point of the existing literature. However, these estimates may mask substantial differences in tax-price responsiveness across subsets of workers. Our more disaggregated analysis reveals tax price responsiveness to be significantly above average for low-income workers, workers with low health risks, and workers in small firms--precisely those groups whose continued participation in employment-related risk pooling is of greatest policy concern. In addition, we present family-level elasticities that allow for joint decision-making in two-worker families.

Why did employee health insurance contributions rise?

We explore the causes of the dramatic rise in employee contributions to health insurance over the past two decades. In 1982, 44% of those who were covered by their employer-provided health insurance had their costs fully financed by their employer, but by 1998 this had fallen to 28%. We discuss the theory of why employers might shift premiums to their employees, and empirically model the role of four factors suggested by the theory. We find that there was a large impact of falling tax rates, rising eligibility for insurance through the Medicaid system, rising medical costs, and increased managed care penetration. Overall, this set of factors can explain more than one-half of the rise in employee premiums over the 1982-1996 period.

Employment Transitions And Continuity of Health Insurance: Implications For Premium Assistance Programs

We use data from two nationwide panel surveys to explore whether premium assistance programs can provide stable insurance for low-income children. We estimate that low-income children who are newly enrolled in an employer-group plan would keep that coverage longer than similar children keep newly acquired public insurance. We conclude that group coverage could provide a source of insurance for eligible low-income children that is more stable than public insurance. However, only one-third of low-income uninsured children have access to group insurance, and most low-income children with access to a group plan are enrolled in it. Thus, premium assistance programs are difficult to target effectively, and other programs are necessary to reach the majority of uninsured children.

Workers' decisions to take-up offered health insurance coverage: assessing the importance of out-of-pocket premium costs

BACKGROUND

Many proposed policy initiatives involve subsidies directed toward encouraging employers to offer coverage and toward workers to encourage enrollment in offered plans. Given that insurance coverage reflects employers' decisions to offer coverage, eligibility requirements for such coverage, and employees' take-up decisions, all three elements are important when considering mechanisms to decrease the number of uninsured individuals.

RESEARCH DESIGN

In this study, we examine the relationship between workers' decisions to take-up offers of health insurance and annual out-of-pocket contributions, total premiums, and employer and workforce characteristics. We model the take-up decision using cross-sectional data from approximately 18,000 establishments per year from the 1997 to 1999 Medical Expenditure Panel Survey - Insurance Component.

RESULTS

We find that workers are less likely to enroll in coverage as single employee contributions increase. Our results for family contributions are much smaller than for single contributions and are not statistically significant in all years. Our simulation results suggest that reducing employee contribution levels for single coverage from existing levels in 1999 to zero would yield an increase in take-up rates of roughly 6% points in establishments that had required a positive level of contributions. Our results also indicate that of the 13.8 million private sector workers who decline coverage from their employers, 2.5 million would potentially enroll in employer-sponsored coverage if the cost of single coverage were to fall to zero.

CONCLUSION

Reducing employee contributions will increase take-up rates; however, even when employees pay nothing for their coverage, some employees elect not to enroll.

Design strategies and innovations in the medical expenditure panel survey

BACKGROUND

Recent efforts to provide an annual profile of the health care quality of the nation's health care delivery system and to identify health care disparities in the population's access to and use of health care services have served to stimulate design innovations and content enhancements to the Medical Expenditure Panel Survey (MEPS).

OBJECTIVES

To present a summary of the analytical objectives, design, and core content of the MEPS, and to provide an overview of the new and innovative design features that add capacity for health status and quality of care measurement and improve data quality.

SUMMARY

The MEPS questionnaire has been expanded to include content taken from the Consumer Assessment of Health Plans Study (CAHPS) to facilitate assessments of patient experiences with health care at the national level. The survey now includes the series of questions from the SF-12 and the EuroQol 5D to improve the survey's capacity to measure health status. Additional condition-specific questions for diabetes, asthma, high blood pressure, and heart disease were added to identify the health care services received for treatment and to determine whether the care received was consistent with practice guidelines. Sample design modifications are presented, with particular emphasis given to a summary of the recent sample size increase and resultant improvements in the precision of resultant survey estimates. Attention is also given to changes in survey design, estimation, and data collection strategies that improve data quality.

How do patients choose physicians? Evidence from a national survey of enrollees in employment-related health plans

OBJECTIVE

This study examines the process by which patients search for and choose physicians.

DATA SOURCE

A survey to a random sample of individuals between the ages of 21 and 64 with employer-related health benefits, drawn from a nationally representative panel of households.

STUDY DESIGN

Logit models are used to measure the effect of patient characteristics on the probability of (1) using alternative sources of information to support the choice of a current physician, (2) seriously considering another physician before choosing a current physician, and (3) stating a willingness to switch physicians when information suggests that other health plan doctors receive higher quality ratings.

PRINCIPAL FINDINGS

Although a minority of respondents actively searches for a physician, there appears to be substantial variation in the degree of consumer activism across patient subgroups. Poor health status, higher levels of service use in the past year, and stronger ties to individual physicians are associated with less consumer activism. At the same time, greater levels of consumer activism were found among racial and ethnic minorities, among those who report using information to choose their physicians, and among those who switched physicians as a result of dissatisfaction some time in the past five years. Source of quality information (medical experts versus patient advocates) did not influence stated willingness to switch physicians.

CONCLUSIONS

Despite predictions of the increasing importance of consumer choice in shaping the health care delivery system, the results largely confirm the image depicted in the previous literature of patients as passive health care consumers of physician services, and highlight the importance of investments in the development of decision support tools in consumer-driven health care systems.

Reform and remembrance: the place of the private sector in the future of health care policy

Although the nation failed during the past decade to enact large-scale, structural change in government health policy, it has seen health care in the private sector remodeled dramatically during the same period. In this article I argue that a new round of equally significant changes is quite possible, this time at the hands of the national government. More specifically, I argue that for a variety of reasons, both enduring and more recently born, support for the private sector and the market in health care is relatively weak: that given likely trends in costs, demographics, and inequalities, it is likely to get even weaker; and that in the potential coming crisis of the health care system. there will be a real opportunity for seizing the agenda and winning policy battles on the part of would-be reformers pushing large-scale, public sector-oriented changes that go well beyond the recent reform efforts directed at managed care and HMOs.

Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999

We examine the roles that insurance coverage, the delivery system, and external factors play in explaining persistent disparities in access among racial and ethnic groups of all ages. Using data from the 1996-1999 Medical Expenditure Panel Surveys and regression-based decomposition methods, we find that our measures of health care system capacity explain little and that while insurance clearly matters, external factors are equally important. Employment, job characteristics, and marital status are key determinants of disparities in access to insurance but are difficult for health policy to affect directly. Much of existing disparities remains unexplained, presenting a challenge to developing policies to eliminate them.