Health care access and use among low-income children: who fares best?

In this paper we assess how access to care and use of services among low-income children vary by insurance status. Although 40 percent of low-income children rely on private health insurance, little is known about how this coverage compares with Medicaid coverage in meeting their health care needs. We find that Medicaid and privately insured low-income children appear to have fairly comparable access but that Medicaid-covered children are more likely to receive services and to have more visits when they receive care. Expanding public coverage may not be sufficient to ensure that all low-income children have access to comprehensive and high-quality care. It may require improvements in preventive and dental care for children with private coverage, an area in which states have limited influence.

The impact of malpractice fears on cesarean section rates.

A longstanding issue in the health care industry is whether physicians' malpractice fears lead to defensive medicine. We use national birth certificate data from 1990 through 1992 to conduct a county fixed-effects analysis of the impact of malpractice claims risk on cesarean-section rates and infant health. Malpractice claims risk is measured by obstetricians' malpractice premiums. The study provides evidence that physicians practice defensive medicine in obstetrics but that the impact of increased cesarean sections that results from malpractice fears on total obstetric care costs is small. The study also finds that physicians' defensive response varies with the socioeconomic status of the mother.

Medical malpractice liability and its effect on prenatal care utilization and infant health.

In this paper we conduct the first national evaluation of the effect of malpractice liability pressure, as measured by malpractice premiums, on prenatal care utilization and infant health. Our results indicate that a decrease in malpractice premiums that would result from a feasible policy reform would lead to a decrease in the incidence of late prenatal care by between 3.0 and 5.9% for black women and between 2.2 and 4.7% for white women. Although, we found evidence that malpractice liability pressure was associated with greater prenatal care delay and fewer prenatal care visits, we did not find evidence that such pressure negatively affected infant health.

Did the Medicaid expansions for children displace private insurance? An analysis using the SIPP.

Using data from the 1990 panel of the Survey of Income and Program Participation (SIPP), we address the question: Did the Medicaid expansions for children cause declines in private coverage? We use a multivariate approach that attributes a displacement effect to declines in private coverage for children targeted by the Medicaid expansions exceeding declines for a comparison group of older low-income children. We find that 23% of the movement from private coverage to Medicaid due to the expansions was attributable to displacement. There is no evidence of displacement among those starting uninsured, leading to an overall displacement effect of 4%.

Changes in prenatal care timing and low birth weight by race and socioeconomic status: implications for the Medicaid expansions for pregnant women.

OBJECTIVE: To conduct the first national study that assesses whether the Medicaid expansions for pregnant women, legislated by Congress over a decade ago, met the policy objectives of improved access to care and birth outcomes for poor and near-poor women. DATA SOURCES/STUDY SETTING: Data on 8.1 million births using the 1980, 1986, and 1993 National Natality Files. We use births from all areas of the United States except California, Texas, Washington, and upstate New York. METHODS: We conduct a before and after analysis that compares obstetrical outcomes by race and socioeconomic status for the periods 1980-86 and 1986-93. We examine whether women of low socioeconomic status showed greater improvements in outcomes during the 1986-93 period compared to the 1980-86 period. We analyze two obstetrical outcomes: the rate of late initiation of prenatal care and the rate of low birth weight. DATA COLLECTION: Natality data were aggregated to race, socioeconomic status, age, and parity groups. RESULTS: During the 1986-93 period, rates of late initiation of prenatal care decreased by 6.0 to 7.8 percentage points beyond changes estimated for the 1980-86 period for both white and African American women of low socioeconomic status. For some white women of low socioeconomic status, the rate of low birth weight was reduced by 0.26 to 0.37 percentage points between 1986 and 1993 relative to the earlier period. Other white women of low socioeconomic status and all African American women of low socioeconomic status showed no relative improvement in the rate of low birth weight during the 1986-93 period. CONCLUSIONS: The expansions in Medicaid lead to significant improvements in prenatal care utilization among women of low socioeconomic status. The emerging lesson from the Medicaid expansions, however, is that increased access to primary care is not adequate if the goal is to narrow the gap in newborn health between poor and nonpoor populations.

Comparison of rural and urban skilled nursing facility benefit use.

In this article, differences in use of Medicare's skilled nursing facility (SNF) benefit in urban and rural areas are examined. Using SNF benefit bills from 1987, the study finds that there appear to be systematic differences by residential location both in the level of use of the benefit and in whether enrollees are admitted to nursing homes and hospital swing beds. Rural Medicare enrollees use the SNF benefit at a rate that is 15 percent higher than the rate for urban enrollees. Furthermore, the swing-bed program appears to play a critical role in providing access to post-acute care for the rural elderly. In rural areas, almost 29 percent of all SNF benefit admissions are to swing beds.

Changes in Medicare skilled nursing facility benefit admissions.

In this article, the changes in Medicare skilled nursing facility (SNF) benefit admissions from 1983 through 1985 are examined and factors that influence changes in access since the implementation of Medicare's prospective payment system are analyzed. During this period, use of the SNF benefit increased nationally by 21 percent. Multivariate analysis is used to determine factors associated with changes in admissions. Changes in SNF benefit admissions were found to be negatively associated with changes in area hospitals' lengths of stay and changes in hospitals' discharges. Medicaid reimbursement policies were also shown to affect changes in utilization.

Access to care and use of health services by low-income women.

Data from the 1997 National Survey of America's Families (NSAF) are used to analyze access to care and use of health care services for low-income women. Three groups of women are examined: those with Medicaid coverage, those with private coverage, and those with no insurance. Findings show that uninsured women faced larger access barriers and utilized fewer services, particularly preventive care services, than women with either public or private coverage. Access and use did not differ greatly between Medicaid and privately covered women. The results suggest that expansions in coverage, either through Medicaid or through private options, could improve access to care for uninsured women.

Medicare patient access to posthospital skilled nursing facility care.

The willingness of nursing homes to accept any Medicare admissions (Medicare participation) and the number of patients they serve (Medicare utilization) affect the access of Medicare SNF patients to posthospital care. Characteristics of facilities, their market areas, and state Medicaid reimbursement were found to affect both participation and utilization. Most important, when Medicaid and private nursing home market conditions support high-intensity care, facilities are more likely to serve Medicare patients and admit more of them. SNFs in states that require Medicare certification are more likely to accept Medicare admissions, suggesting that the cost and effort of achieving certification are a barrier to service to Medicare SNF patients. For-profit facilities, hospital-based SNFs, and larger nursing homes have higher rates of participation and serve more Medicare patients when they serve any.

The effects of Medicaid reimbursement method and ownership on nursing home costs, case mix, and staffing.

In this study we analyze the effects of ownership and Medicaid cost containment initiatives on nursing home costs, payer mix, case mix, and staffing, using 1981 Medicare cost reports and Medicare/Medicaid Automated Certification files. As Medicaid cost containment incentives become stronger, nursing homes respond by decreasing case mix and commensurately decreasing staffing. When these incentives are especially strong, staffing is reduced beyond the apparently appropriate level, given the case mix. In addition, while chain facilities have lower costs than other types of facilities, these lower costs do not appear to come from either increased cream-skimming or reduced staffing levels.

Medicaid expansions for pregnant women and infants: easing hospitals' uncompensated care burdens?

Hospitals' bad debt and charity care increased by nearly 30% between 1987 and 1990. However, beginning in 1987, federal legislation expanded Medicaid eligibility to pregnant women and infants with family incomes up to 133% of the federal poverty level, and gave states the option to extend coverage up to 185% of poverty. These expansions likely reduced the need for free hospital care. Controlling for other factors associated with provision of uncompensated care, this analysis shows the Medicaid expansions reduced uncompensated care by roughly 5.4%. For hospitals with a significant commitment to maternity and infant care, the burdens of uncompensated care were 28.5% lower than they would have been without the expansions.

Explaining urban-rural differences in the use of skilled nursing facility benefit.

Recent closings of rural hospitals, anecdotal evidence of rural elderly persons having difficulty gaining access to health services, and the large and growing number of elderly persons living in rural areas has renewed concern about access to care for the rural elderly. In this study, 1987 Medicare skilled nursing Facility (SNF) bills were used to examine differences in urban and rural use of the SNF benefit. Using multivariate techniques, the analysis found that Medicare enrollees living in rural and large metropolitan areas used the SNF benefit at a rate 20% and 17% higher than enrollees living in small and medium-sized metropolitan areas, respectively. However, in rural areas the swing-bed program plays a major role in assuring access to the SNF benefit. Without the swing-bed program, rural enrollees would use the SNF benefit at a rate comparable to that of enrollees in small and medium-sized metropolitan areas. The importance of the swing-bed program cannot be underscored, because relative to urban enrollees, rural enrollees disproportionately live in nursing home markets that are not amenable to serving Medicare patients.

Assessing SCHIP effects using household survey data: promises and pitfalls.

OBJECTIVES: To describe how household surveys can be used to assess the effects of the new State Children's Health insurance Program (SCHIP) , review methodologic issues associated with household survey data, and propose solutions for dealing with these issues. PRINCIPAL FINDINGS: To estimate the effect of SCHIP, analysis must explicitly recognize and control for the fact that other factors that could affect the outcomes of interest besides the new program will change over the analysis period. In assessing SCHIP's effect, SCHIP-eligible children must be identified using a detailed simulation model. Analyses that use either a simple eligibility model or only examine children with incomes between 100 and 200 percent of poverty will not accurately identify SCHIP-eligible children. Under these circumstances estimates of the effect of SCHIP will be biased downward. In addition analyses must rely on the same survey in the pre- and post- SCHIP periods to obtain reliable estimates. Moreover, the survey must attempt to obtain data on separate SCHIP programs, and analysts must consider the implications of the possible increasing underreporting of public health insurance coverage. Finally, analysts should be cautious about evaluating SCHIP's success before the program is mature. CONCLUSION: While evaluating SCHIP using household surveys has some challenges, if conducted carefully such analyses will provide important in formation on the effect of the SCHIP program that can not be obtained elsewhere.