Lecture 8 - 9/26/99

Findings: Policies Aimed at Increasing Availability of Coverage

• Changes in underwriting rules -- guaranteed issue/renewability, pre-existing conditions waiting periods, portability of coverage all no effect

Why Availability Reforms Have Not Had greater Impact on Uninsured

• Medical underwriting problem not as great as was thought
• Even with new regs., insureres able to risk select in provision of benefits and use allowable degree of rating flexibility

Community rating laws accelerated trend towards HMOs

The American Health Care System: Health Insurance Coverage - Robert Kuttner

Why Insurance Coverage is Eroding

• Rising premiums
• Changes in employment mix--growth of temporary and part-time workers
• Reduction in explicit coverage, e.g., for drugs
• Greater limitations of covered care, esp. by HMOs
• Shift from HMOs to PPOs --> increase in cost sharing
• Loss of Medicaid from welfare reform
• Rising cost of "Medigap" coverage
• Reduction in services to legal and illegal aliens
• Trend away from community rating

Correlates of Being Uninsured

• Low income (person at poverty pays 26% of income for health insurance)
• Lack (loss) of employment
• Change in family status (not mentioned in article)

Students Read

• Children without insurance
• The underinsured
• Pharmaceutical coverage (note sources from Lewin group)

Sex Differences in Use of Health Care Services

Cameron Mustard, Patricia Kaufert, Anita Kozyrskj, and Teresa Mayer

Methods

• Source of data: Manitoba Health Services Insurance Plan
• Had information from registry file (all persons eligible to receive insurance), physicians' claims file, hospital discharge abstracts
• Measures: spending on physicians' and hospital services, use for sex-specific conditions, mortality, use at end of life

Key Findings

• Per capita expenditure for MD services $277 for females, $198 for males (ratio1.4)
• Per capita expenditure for hospital $887 for females, $720 for males (ratio 1.2)
• Male spending higher for persons <10 and >59 (Fig. 1) (more apparent for older group)
• 32% of female and 17% of male spending attributed to care associated with sex-specific conditions
• Small differences in end-of-life care spending by gender: males $15,400; females $14,900.  Greater variation for specific conditions (Table 3), but small sample size

Discussion

• Study confirms little difference in spending by gender, especially after accounting for gender-specific use
• Some noteworthy difference in spending on males at older ages

Effects of Race and Income on Mortality and Use Among Medicare Beneficiaries

Gornick et al.

Issues

• How do race and income affect mortality and use of services covered by Mediare?
• How much do racial differences decrease when one adjusts for income?

Methods

• Medicare data
• Census data
• Merge
• Statistical analysis
• Validation

See tables and figures in the article (coursepack)

Results

• Characteristics of respondents by race
• Mortality by race/gender, income
• Physician vists by race and income
• Hospital use and use of procedures for ischemic heart disease
• Mammography, hip fracture, amputation, and bilateral orchietomy rates
• Summary of effects of adjusting for income

Questions for Discussion

• Why does race affect mortality and use of services?
• What can policymakers do to narrow these differences?
• How would you improve the study?