Underinsurance in the United States: an interaction of costs to consumers, benefit design, and access to care.

Underinsurance is most commonly defined as the state in which people with medical coverage are still exposed to financial risk. We argue that the adequacy of health insurance coverage should also be assessed in terms of the adequacy of specific benefits coverage and access to care. Underinsurance can be understood conceptually as comprising three separate domains: (a) the economic features of health insurance, (b) the benefits covered, and (c) access to health services. The literature provides ample evidence that people who are underinsured have high financial risk and face barriers in access to care similar to those who are completely uninsured. In response to the growing recognition of the problems associated with underinsurance, the Patient Protection and Affordable Care Act of 2010 includes numerous provisions designed to limit costs to consumers, to assure a minimum set of benefits, and to enhance access to care, especially primary care.

Switching health insurance and its effects on access to physician services.

BACKGROUND: This study examines the factors associated with discontinuous health insurance coverage without periods of uninsurance during the past year (ie, switching coverage), and whether it has a detrimental effect on basic access to care. RESEARCH DESIGN: We analyze the 2003 California Health Interview Survey samples of adults, ages 19-64 (n = 32,850) and children, ages 0-18 (n = 13,062), using weighted bivariate and multivariate analyses. We stratified the population first by age (modeling adults separately from children) and then by health status (modeling the full population and the population reporting fair or poor health separately). RESULTS: Income, race/ethnicity, age, gender, and rural status were significant factors associated with switching coverage. Adults who switched insurance had significantly reduced odds of having a usual source of care [odds ratio (OR) = 0.63, P < 0.001)] compared with those with continuous coverage. In addition, adults and children who switched coverage were significantly more likely to report delaying care because of cost or insurance issues (adults: OR = 1.65, P < 0.001; children: OR = 2.00, P < 0.001). Children in fair or poor health who switched insurance coverage had much higher odds of reporting a delay in care (OR = 5.48, P < 0.001). CONCLUSIONS: Children and adults had disruptions in their basic access to health care when they experienced discontinuous insurance. These findings highlight the advantages of retention of enrollees as one means of promoting access to health care, in the short term, and the benefit of a continuous national health insurance program in the long term.

The impact of private and public health insurance on medication use for adults with chronic diseases.

This article examines the impact of public and private health insurance on the use of medications for California adults with any of four chronic diseases: heart disease, high blood pressure, diabetes, and asthma. The data set used is the 2001 California Health Interview Survey. Multivariate analyses were conducted on individuals who had been diagnosed with each of these diseases. Controlling for various demographic, health status, and employment characteristics, the authors find that the uninsured are far less likely to be taking medications for each of the conditions than those with private insurance. Interestingly, those with Medicaid coverage are even more likely than those with private insurance to be taking such medications. The results of this study underscore the importance of health insurance for all persons with chronic conditions and the benefits of Medicaid in particular for low-income adults with chronic conditions.

The California Health Interview Survey 2001: translation of a major survey for California's multiethnic population.

The cultural and linguistic diversity of the U.S. population presents challenges to the design and implementation of population-based surveys that serve to inform public policies. Information derived from such surveys may be less than representative if groups with limited or no English language skills are not included. The California Health Interview Survey (CHIS), first administered in 2001, is a population-based health survey of more than 55,000 California households. This article describes the process that the designers of CHIS 2001 underwent in culturally adapting the survey and translating it into an unprecedented number of languages: Spanish, Chinese, Vietnamese, Korean, and Khmer. The multiethnic and multilingual CHIS 2001 illustrates the importance of cultural and linguistic adaptation in raising the quality of population-based surveys, especially when the populations they intend to represent are as diverse as California's.

Patient-centered medical homes improve care for adults with chronic conditions.

The success of health care reform implementation in 2014 partly depends on more efficient delivery of care to the millions of California residents eligible to gain insurance. Emerging evidence supports the effectiveness of the patient-centered medical home (PCMH) as a potential model of care delivery, which improves health outcomes and reduces costs. Among other principles, PCMH entails receipt of care from a personal doctor, who coordinates the patient's care and develops an individualized treatment plan for the patient. These principles are particularly essential in delivery of care to those with chronic conditions who require more intensive care management. Using the 2009 California Health Interview Survey (CHIS 2009), this policy brief indicates that patients who reported meeting these fundamental PCMH principles were more likely to have visited the doctor and to have received flu shots, and they also had better communication with providers than those who did not report meeting these PCMH principles. The data also showed that uninsured individuals, Medi-Cal beneficiaries, those at or below 133% of the federal poverty level, Latinos, and Asian-Americans were less likely to report meeting all three PCMH principles. These findings highlight the population groups that would most benefit from the PCMH care delivery model, particularly Medi-Cal beneficiaries and those eligible for Covered California, the California health benefits exchange.

The effects of the Great Recession on health insurance: changes in the uninsured population from 2007 to 2009.

The economic recession that began in California in 2008 did not affect all counties equally. Using data from several years of the California Health Interview Survey, this policy brief examines the differences between 2007 and 2009 for the populations who were uninsured "for all or part of the prior year." During this time period, counties with high unemployment and lower household income saw the highest growth in the uninsured population, due to a large drop in job-based coverage and only a small increase in public coverage. Compared to the uninsured population in California in 2007, Californians who were uninsured for all or part of 2009 were older, more likely to be U.S.-born citizens, had lower household incomes, and were more likely to be unemployed and looking for work.

Two-thirds of California's seven million uninsured may obtain coverage under health care reform.

Almost 4.7 million nonelderly adults and children of the seven million Californians who were uninsured for all or part of 2009 will be eligible for insurance as a result of last year's health care reform legislation, according to new data from the 2009 California Health Interview Survey (CHIS 2009). Eligible Californians will obtain coverage either through Medi-Cal or through subsidies to purchase private health insurance in the new California Health Benefit Exchange (CHBE) starting in 2014. The CHBE will also be open to 1.2 million uninsured persons who do not qualify for subsidized premiums due to their income exceeding eligibility levels, but who will benefit from the new marketplace created through the Patient Protection and Affordable Care Act (PPACA). Just over one million uninsured persons do not qualify to participate in either the CHBE or in the Medi-Cal expansion due to their citizenship status. With seven million uninsured residents of California in 2009, the new insurance options made available by the PPACA could face challenges in enrolling these uninsured individuals.

The impact of health care reform on California's children in immigrant families.

The Patient Protection and Affordable Care Act of 2010 (ACA) restricts its health insurance expansions in ways that exclude many uninsured children in California who are immigrants or have immigrant parents. These exclusions directly limit coverage options for noncitizen children. And immigrant parents, potentially misinterpreting eligibility requirements for these new programs, may not enroll their citizen children. Using the 2007 California Health Interview Survey (CHIS 2007), this policy brief estimates that of the 1.08 million children in California who were uninsured all or part of the year, between 180,000 to 220,000 will be excluded from the health care reform expansions due to the combined direct and potential indirect effects of these exclusions. This "left-out" group comprises between 17% and 20% of all uninsured children in California. In light of these exclusions, California's community clinics and public hospitals could continue to serve a significant number of uninsured immigrant children even after full implementation of ACA.

One-fifth of nonelderly Californians do not have access to job-based health insurance coverage.

Lack of job-based health insurance does not affect just workers, but entire families who depend on job-based coverage for their health care. This policy brief shows that in 2007 one-fifth of all Californians ages 0-64 who lived in households where at least one family member was employed did not have access to job-based coverage. Among adults with no access to job-based coverage through their own or a spouse's job, nearly two-thirds remained uninsured. In contrast, the majority of children with no access to health insurance through a parent obtained public health insurance, highlighting the importance of such programs. Low-income, Latino and small business employees were more likely to have no access to job-based insurance. Provisions enacted under national health care reform (the Patient Protection and Affordable Care Act of 2010) will aid some of these populations in accessing health insurance coverage.

The effects of varying periods of uninsurance on children's access to health care.

OBJECTIVE: Many studies have documented the adverse consequences of uninsurance for children, but less is known about the differential effects of varying periods of uninsurance. This study examines the relative effects of varying periods of uninsurance (uninsured for 1-4 months, 5-11 months, or all year) on children's access to care. METHODS: Using data from the 2005 California Health Interview Survey Children's File (ages 0-11), we estimated logistic regressions to examine the effect of insurance status on 6 measures of health care access, controlling for child demographics, child health status, family characteristics, and urban residence. Indicators for insurance status included the following categories: (1) privately insured all year (reference); (2) Medicaid all year; (3) State Children's Health Insurance Program all year; (4) uninsured for 1 to 4 months; (5) uninsured for 5 to 11 months; (6) uninsured all year; and (7) other insurance all year. RESULTS: We found that children who experience short spells of uninsurance (1-4 months) are less likely to have a usual source of care and are more likely to experience delays in needed care than those with continuous private or public insurance. The consequences are even worse for children who experience more substantial periods of uninsurance, because they are also less likely to receive preventive care (well-child visits and flu shots) or visit the doctor during the year and are more likely to experience delays in receiving needed medical care and prescriptions than those with continuous coverage. The Medicaid program and State Children's Health Insurance Program in California both seem to have ensured levels of health care access similar to that obtained by children with year-round private coverage. CONCLUSIONS: These findings highlight the benefits gained through continuous health insurance, whether public or private. Public policies should be adopted to ensure continuity of coverage and retention in public insurance programs.

One in five Californians were uninsured in 2005 despite modest gains in coverage.

Six and one-half million Californians were uninsured for all or some of 2005, a number that is as large as the combined populations of nine other states. The number of uninsured represented one in five children and nonelderly adults, a rate that was slightly lower than in 2003 due to California's tight labor markets and expanding enrollment and retention in California's public coverage programs for children. These marginal improvements are unlikely to continue unabated given the instability of employment-based insurance coverage in the face of rising costs. In this policy brief, we compare insurance coverage over time using the California Health Interview Surveys conducted in 2001, 2003 and 2005. We look at the type of coverage over the past 12 months for both children and nonelederly adults.

Job-based coverage drops for adults and children but public programs boost children's coverage.

Based on data from the 2003 California Health Interview Survey (CHIS 2003), this policy brief provides a profile of nonelderly Californians' health insurance coverage and lack of coverage, as well as estimates of children and adults who are uninsured but eligible for coverage through public programs. It also describes how this profile has changed since 2001, based on data from CHIS 2001.