Universal Health Insurance in Massachusetts:

The Massachusetts Health Security Act is the first universal-access financing legislation in the country, and sets a precedent for providing health coverage for the 600,000 uninsured in the state. The bill is the product of prolonged negotiation among hospitals, business interests, insurers, and advocates of universal access, who debated the extent of benefits, the cost of care, and the system which will monitor and regulate its provision. While the bill represents an important first step in addressing the service requirements of the uninsured, it falls short of meeting the needs of the underinsured, for example, elderly persons unable to afford Medex insurance to supplement Medicare coverage. The article reviews the points of negotiation which led to adoption of the bill.     

Expanding the focus of health insurance education for Medicare beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Expanding the Focus of Health Insurance Education for Medicare Beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Understanding the diverse needs of the Medicare population: implications for Medicare reform

Meeting the health care needs of millions of elderly and disabled Americans is central to the debate over Medicare's future. Using data from a nationally representative survey of 3,309 beneficiaries, Medicare's most vulnerable beneficiaries were profiled, examining variations in coverage, satisfaction, access, and financial difficulties. A substantial portion of the Medicare population--two thirds--were found to have health problems or low incomes. The analysis found that about 40% of beneficiaries with incomes below the poverty level, in fair or poor health, or with ADL limitations, have difficulties paying their medical bills or getting needed health care. Medicare's disabled, under-65 beneficiaries are at even higher risk: nearly half (47%) have health care access problems or deal with financial hardship due to medical bills. The diverse needs and experiences of the Medicare population are underscored, providing new insights into the challenge of maintaining or improving protection for those with greatest need while assuring the long-term fiscal viability of the program.     

Neighborhood socioeconomic disadvantage and access to health care

Most research on access to health care focuses on individual-level determinants such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed care, however, has not received much attention. We address this gap in the literature by examining how neighborhood socioeconomic disadvantage is associated with access to health care. We find that living in disadvantaged neighborhoods reduces the likelihood of having a usual source of care and of obtaining recommended preventive services, while it increases the likelihood of having unmet medical need. These associations are not explained by the supply of health care providers. Furthermore, though controlling for individual-level characteristics reduces the association between neighborhood disadvantage and access to health care, a significant association remains. This suggests that when individuals who are disadvantaged are concentrated into specific areas, disadvantage becomes an "emergent characteristic " of those areas that predicts the ability of residents to obtain health care.     

The importance of employer sponsorship in the long-term care insurance market

Medicare and Medicaid are major sources of long-term care payments and thus will bear much of the burden from the growth in long-term care service use. The large future demand for long-term care services is of great concern among policymakers due to its expense and the use of public program dollars. It is argued that the individual purchase of long-term care insurance can help alleviate the increasing financial pressure on public programs responsible for the majority of longterm care financing. However, consumers have shown little interest in insuring against the high costs of long-term care. This analysis examines the effect of several factors on the decision to purchase a long-term care insurance policy: knowledge and attitudes of long-term care insurance and the long-term care financing system, the perceived risk for longterm care, financial planning behavior, and the availability of long-term care insurance. The interim results indicate the factor most likely to affect the decision to purchase long-term care insurance is access to employer-sponsored long-term care insurance. This suggests tht the availability of affordable and high quality coverage is more important than demand-side factors such as awareness of long-term care insurance and a perceived greater risk for long-term care.     

Characteristics of the nonelderly with selected sources of health insurance and lengths of uninsured spells

This Issue Brief examines the characteristics of individuals with selected sources of coverage and combinations of sources of coverage over a 12-month period. In addition, it examines the characteristics of individuals who experience spells without health insurance and the lengths of these spells. It uses the most recent 12-month period from the Survey of Income and Program Participation and builds on previous research on the lengths of spells with and without health insurance. Analysis of individuals' health insurance coverage from October 1994 to September 1995 showed that approximately 77.6 percent of the nonelderly had health insurance coverage during this entire period. In addition, 22.4 percent of the nonelderly were uninsured for at least one month during this period, and 7.4 percent of the nonelderly were uninsured for the entire period. Of those with health insurance coverage for the entire year, approximately 83 percent were covered by private health insurance, with at least 81 percent of this group receiving the coverage from employment-based sources. Eighty-five percent of the spells without health insurance with an observed beginning and end lasted for 4 months or less, and 99 percent lasted for 8 months or less. When examining the spells with either an observed beginning or end, 55 percent of these spells were found to last for 4 months or less, and 87 percent were found to last for 8 months or less. However, investigation of all spells without health insurance showed that approximately one-half of all spells without health insurance coverage lasted for 8 months or longer. This report found that two-thirds of spells without health insurance last for less than one year, confirming previous research that a majority of these spells are for less than a year. However, this report also confirms the existence of a significant number--approximately one-third of all individuals with a spell of noncoverage--of chronically uninsured individuals. These individuals are the most likely to delay seeking treatment for illnesses and to use the emergency room as their only site of care. Because they are in poverty or near poverty, much of this care is uncompensated. Thus, to the extent that providers can shift these costs onto other payers, all individuals and employers share in these costs through higher health insurance premiums or higher taxes to finance public hospitals and public insurance programs. Recent major health insurance legislation has addressed access to health insurance, and in many cases focused solely on continued access to employment-based coverage, but has done very little to address the affordability of coverage. However, as this report demonstrates, many individuals experiencing spells without health insurance have low incomes. Thus, to obtain coverage, individuals need not only increased access to health insurance but also the ability to afford this health insurance.     

Access to health care: does neighborhood residential instability matter?

Many Americans do not have access to adequate medical care. Previous research on this problem focuses primarily on individual-level determinants of access such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed medical care, however, has not received much attention. We address this gap in the literature by investigating the association between neighborhood residential instability and access to health care. Using individual-level data from the 2000 Medical Expenditure Panel Survey and block-group level data from the 2000 decennial census, we find that individuals who live in neighborhoods with high residential turnover have worse health care access than residents of other neighborhoods. This association persists even when the prevalence of poverty, the supply of health care, and a variety of individual characteristics are held constant. We offer explanations for these findings and suggest directions for future research.     

Using the Medicare buy-in program to estimate the effect of Medicaid on SSI participation

This article assesses the importance of receiving supplemental health insurance on participation in Supplemental Security Income (SSI) for the elderly. The implementation of the Qualified Medicare Beneficiary (QMB) program offered a substitute for Medicaid, and expanded health insurance eligibility to a higher income level. Using a sample of elderly respondents aged 66 to 75, I find that the QMB program reduced SSI participation. More than half of the QMB participants were previously covered by SSI and Medicaid. The calculations suggest that the QMB program was not as expensive as it might first appear because of reductions in SSI expenditure.     

Does Health Insurance Premium Exemption Policy for Older People Increase Access to Health Care? Evidence from Ghana

Aging in Sub-Saharan Africa causes major challenges for policy makers in social protection. Our study focuses on Ghana, one of the few Sub-Saharan African countries that passed a National Policy on Aging in 2010. Ghana is also one of the first Sub-Saharan African countries that launched a National Health Insurance Scheme (NHIS; NHIS Act 650, 2003) with the aim to improve access to quality health care for all citizens, and as such can be considered as a means of poverty reduction. Our study assesses whether premium exemption policy under the NHIS that grants non-payments of annual health insurance premiums for older people increases access to health care. We assessed differences in enrollment coverage among four different age groups (18–49, 50–59, 60–69, and 70+). We found higher enrollment for the 70+ and 60–69 age groups. The likelihood of enrollment was 2.7 and 1.7 times higher for the 70+ and 60–69 age groups, respectively. Our results suggest the NHIS exemption policy increases insurance coverage of the aged and their utilization of health care services.