A Longitudinal Model of Health Insurance: Employer Sponsored Insurance

To improve our understanding of the trends in health care coverage and costs, available data is being reevaluated. For years, this data has been used to estate costs and coverage, to identify trends, and to form policy regarding health insurance and health benefits. This report was initiated by ASPE to develop a longitudinal model for tracking the key indicators of employer sponsored insurance (ESI) to facilitate the identification of trends and to offer policy makers a set of consistent single point estimates based on analysis of available data sources. The subsequent longitudinal model developed by the research team is based on the March Current Population Surveys, from March 1990 through March 1998 (CY 1989 through CY 1997). Specific trends to be tracked include, but are not limited to: the overall level of employer sponsored insurance in the US (both counts and as a proportion of the population); the extent of employer sponsored insurance in own name (policy holder prevalence); the extent of employer sponsored insurance as a dependent; the prevalence of dual policy holder families. The authors had to adjust the Current Population Survey (CPS) data because changes in survey and sample frame over time make it less useful for longitudinal study without adjustments. The adjustments were made to the historical data in order to be able to a look at trends in employer sponsored coverage from 1990 to the present. The report concludes by stating that the current set of adjusted files appears to address the problems caused by survey and sample frame changes, and generates coverage estimates roughly consistent with those implied by the Survey of Income and Program Participation.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Greenberg, George
202-690-7794

PIC ID: 7295

PERFORMER: Actuarial Research Corporation
Annandale, VA

All Under One Roof: Mixed -Status Families in an Era of Reform

This report documents the prevalence of mixed immigration status families and discusses some of the immigration and citizenship policies that drive their formation. It identifies a number of the challenges that mixed-status families pose for achieving the goals of recent welfare and illegal immigration reform laws. It explores how recent curbs on noncitizens' use of public benefits may have the unintended effects of "chilling" citizen children's use of benefits. The report examines how recent laws limited undocumented immigrants' ability to adjust from illegal to legal status, effectively perpetuating certain mixed-status families. They do so by freezing a growing number of parents and children into differing statuses: parents as undocumented immigrants or "outsiders", children as citizens or "insiders." The citizen children in these families may not receive the same opportunities as other citizen children due to their parents' legal status. One effect, according to the report, is to treat citizen children in mixed-status families as second-class citizens. One ready solution to this problem would be to eliminate birthright citizenship. However, its adoption would signal a shift toward the approach taken by many European nations, which treat not just newcomers but also their children as outsiders, thereby perpetuating a type of hereditary disadvantage that departs from U.S. historical tradition.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Sanches, Linda
202-690-7233

PIC ID: 7370.2

PERFORMER: Urban Institute
Washington, DC

Analysis of Children's Health Insurance Patterns: Findings from the SIPP Executive Summary

This report summarizes working using the 1992 panel of the Survey of Income and Program Participation (SIPP) to provide the most detailed look yet at the dynamics of health insurance coverage among children and the relationship between Medicaid eligibility and insurance coverage. The findings indicate from October 1992 to September 1994, between 12.4 and 13.3 percent of children under 19 were uninsured at any one point in time, with one in four children (27.1 percent) uninsured for some period of time over the two years. the findings highlight the importance of shifting some attention from studying why children do not enroll in Medicaid to the question of why children lose Medicaid coverage when they may still be eligible. The findings highlight how Medicaid eligibility policy affects the relationships among income, child age, and coverage. The findings also highlight the substantially lower participation rates for children who are not cash assistance participants. This reinforces the importance of strong outreach to achieving high levels of CHIP participation and highlights ways of targeting outreach to reach diverse subsets of children. The findings also highlight the importance of not just enrolling children in Medicaid or CHIP but also retaining them in the programs.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Stewart, Robert
202-690-7273

PIC ID: 7355

PERFORMER: Mathematica Policy Research, Inc.
Washington, DC

Analysis of Prescription Drug to Over-the-Counter (Rx-to-OTC) Switch Movement

Approximately 600 over-the-counter (OTC) products currently available use ingredients and dosages available only by prescription 20 years ago. While there has been a steady stream of OTC switches since the mid-1970s, the number of switches has accelerated in recent years. Between 1988 and 1994 there were 14 switches, while in the last three years there were at least 19 switches. There are a number of possible reasons for this trend, including: (1) a growing emphasis on individual autonomy and self-help; (2) a trend toward deregulation in the U.S.; (3) healthcare cost containment efforts; and (4) pharmaceutical industry self-interest /profit. The issue of Rx-to-OTC switching deserves considerable attention because of the large number of people who could be affected by the trend, including consumers, pharmaceutical companies, physicians, pharmacists, and payers. The purpose of this project was to provide a comprehensive review and analysis of the impact of the Rx-to-OTC switch movement, particularly the more recent changes, in order to inform policy and define relevant research questions. The study contains a literature review on the subject; a summary of interviews with such key informants as pharmacists, consumers, and physicians; data analyses providing evidence of the magnitude of OTC sales and the importance of recent switch drugs within the OTC market; analyses related to the impact of OTC switch drugs on clinical practice patterns; and data from state Medicaid plan coverage of OTCs.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Bush, Laina
202-260-7329

PIC ID: 6723

PERFORMER: Northwestern University, Center for Health Services Policy
Evanston IL

Assessing the Performance of Organ Transplant Programs: Liver and Heart Transplantation

In its role under the National Organ Transplant Act as the responsible steward of the program of solid organ transplantation in the United States, the Department of Health and Human Services has carried out analyses of the three critical issues in transplantation... (1) What is the likelihood that, having been declared a transplant patient by being placed on a waiting list, the patient will actually receive an organ within a reasonable amount of time, say one year? (2) What is the likelihood that the patient will, instead, die while awaiting transplantation? (3) And what is the probability that the patient will still be alive one year after having been placed on the waiting list, whether or not he or she received a transplant? The findings indicated in both liver and heart transplantation, about two-thirds of the deaths within a year of listing occur while awaiting the transplant. The two measures of mortality are strongly correlate, with about 50% of the variation among centers in risk-adjusted survival accounted for by risk-adjusted mortality on the waiting list. In contrast, there is little correlation between the risk-adjusted rate of transplantation and risk-adjusted survival, none in the case of the liver. This reinforces the point that the early performance of a transplant is not necessarily the best care that can be provided to a patient. The best care consists of a broad constellation of practices of the listing center and of other hospitals and care-givers to which the patient is subjected while awaiting transplantation, as well as during and after the transplantation itself.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Krakauer, Henry
202-690-7771

PIC ID: 7354

PERFORMER: Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy
Washington, DC

Baseline Information for Evaluating the Implementation of the Health Insurance Portability and Accountability Act of 1996: Final Report

The Health Insurance Portability and Accountability Act (HIPAA) ensures access to insurance for some employer groups and individuals who previously were unable to purchase adequate coverage. The Department of Health and Human Services is required to report to Congress on the effects. Therefore the Health Care Financing Administration contracted with RAND and the Institute for Health Policy Solutions (IHPS) to develop the contextual information needed for an evaluation and to develop a design for the evaluation. Four central tasks were accomplished and reported in this final report: (1) developed a database which describes the regulatory environment in each state prior to HIPAA to measure regulatory actions states have taken to comply with HIPAA's requirements; (2) reviewed the literature to address issues that have arisen during HIPPA's implementation and summarized the expected effects of HIPAA's provisions; (3) reviewed the strengths and weaknesses of extant data that might be used in the HIPAA evaluation and (4) developed a plan to evaluate the effects of HIPAA on the accessibility and affordability of insurance in the group and individual insurance markets.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Finan, Stephen
202-690-7387

PIC ID: 7358

PERFORMER: Rand Corporation
Santa Monica, CA

Chartbook on Children's Insurance Status: Tabulations of the March 1998 Current Population Survey December 1998

This chartbook examines demographic and other characteristics of insured and uninsured children in the United States. It is based on data from the March 1998 Current Population Survey (CPS) and reflects children's insurance status during calendar year 1997. For the purposes of this chart book, the term "children" applies to all U.S. citizens and non-citizen residents under age 18. Key findings include: 10.7 million children, 15% of the population under age 18, are uninsured. In the March 1997 survey 10.6 million children or 15% were uninsured; 45 million children (63%) are covered under employer-sponsored insurance. This is consistent with the proportion of individuals in the overall population who are insured through an employer.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Taplin, Caroline
202-690-7906

PIC ID: 7356

PERFORMER: Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy
Washington, DC

Enabling Services Methodology Workshop

Enabling services was defined in a previous study as "services that facilitate access to medical care and/or support individuals in managing medical conditions". This project sought to address enabling services issues by: (1) exchanging information regarding what is known and unknown about enabling services in primary care settings, particularly in managed care environments, costs, efficacy, cost-effectiveness and new research efforts; (2) identifying key policy questions related to enabling services, particularly as used in managed care settings; (3) identifying major methodological questions that studies of these services present, both generally and in managed care settings, and strategies for overcoming them; and (4) developing a broad-based research agenda for consideration by the many public and private sector organizations which pay for, or otherwise have interests in, these services. The report presents findings, identifies questions regarding enabling services from the perspectives of various stakeholder groups, and considers strategies and approaches to addressing questions about enabling services.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Taplin, Caroline
202-690-7906

PIC ID: 6750

PERFORMER: The Lewin Group
Fairfax, VA

Linking State-Level Health Expenditure and Utilization Data to Identify Sources of Variation in Health Service Prices, Utilization, and Expenditures

The debate over comprehensive health reform in 1993 and 1994 revealed many strengths and weaknesses in the U.S. health care system. The policy development process underlying that debate exposed the limits of collective analytic capacity to explain the implications of expected changes in our health system. Due to budget constraints, the research community is severely limited in supporting state-specific estimates and data. This Urban Institute report accesses the combination of the expenditure data from The Health Care Financing Administration, with utilization data from The Health Resources and Services Administration to yield state- and service-specific prices that are analytically meaningful. The major finding is that the empirical models at the state level performed reasonably well - over 80% of the variance in the inpatient dependent variables (prices, utilization, and expenditures) is explained, as well as over 50% of the variance in these variables for outpatient services. This kind of model could be useful for both federal and state policy analysts to analyze market trends and to stimulate the effects of proposed policies.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Greenberg, George
202-690-7794

PIC ID: 7248

PERFORMER: Urban Institute
Washington, DC

The Child Health Insurance Program: Early Implementation in Six States

Research has demonstrated that children with health insurance coverage have greater access to medical care than those without coverage. On average, those with health insurance visit doctors more frequently than those without coverage. A 1993 survey, for example, found that of all children who had no physician visits in the past year, 39 percent were uninsured compared to 20 percent of children with private coverage. Children with health insurance coverage pay fewer visits to the emergency room in an average year than those without coverage. Those with health insurance develop fewer chronic illnesses, and those they do develop are treated more successfully than the chronic illnesses of uninsured children. To help reduce the number of uninsured children and to increase their access to medical care, Congress established, in 1997, a new Children's Health Insurance Program (CHIP) as Title XXI of the Social Security Act. Intended to supplement--not supplant--Medicaid, CHIP is designed to find and enroll "targeted low-income children" whose family income puts them above the Medicaid eligibility threshold, but below an income level that makes private health insurance premiums affordable. This study was designed to understand and document the decisions in six States regarding the: (1) planning process; (2) key factors affecting the program design in their initial plans submitted to HHS; (3) CHIP program design as a separate State-initiated program, a Medicaid expansion, or a combination; (4) choice of income eligibility levels; (5) parameters of State-initiated health insurance programs implemented prior to CHIP; and (6) implementation of specific features of their CHIP programs during the early months.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Taplin, Caroline
202-690-7906

PIC ID: 6308

PERFORMER: American Institutes for Research
Washington, DC

Trends in Noncitizens' and Citizens' Use of Public Benefits Following Welfare Reform: 1994-97

This report uses the Census Bureau's Current Population Survey (CPS) to document national trends in immigrants' use of public benefits in the period following welfare reform. Specifically, it examines changes in participation between 1994 and 1997 reflected by the March CPS. It is emphasized that most legal immigrants and refugees remained eligible for welfare and Medicaid benefits throughout the period examined (1994 through 1997). The principal findings are: (1) use of public benefits among noncitizen households fell more sharply (35 percent) between 1994 and 1997 than among citizen households (14 percent); (2) refugees experienced declines (33 percent) that were at least as steep as those within the noncitizen population; (3) for low-income populations (i.e., with incomes below 200 percent of poverty), program usage also fell faster for noncitizen than citizen households; (4) when welfare use among all households is examined, noncitizen participation levels were higher than citizens' in both 1994 and 1997, but poor households (i.e., with incomes under 200 percent of poverty), noncitizens' participation rates in 1994 were no different from those of citizens; by 1997, however, levels had declined so that noncitizens had lower participation rates than citizens; (5) neither naturalization nor rising incomes accounted for a significant share of noncitizens' exits from public benefit use.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Sanches, Linda
202-690-7233

PIC ID: 7370.1

PERFORMER: Urban Institute
Washington, DC

Using National Survey Data to Analyze Children's Health Insurance Coverage: An Assessment of Issues

The purpose of this report is to discuss key analytic issues in the use of national survey data to estimate and analyze children's health insurance coverage. One goal was to provide staff in the Office of the Assistant Secretary for Planning and Evaluation (ASPE) with information that will be helpful in reconciling or at least understanding the reasons for the diverse findings reported in the literature on uninsured children. The second major objective was to outline for the broader research community the factors that need to be considered in designing or using surveys to evaluate the number and characteristics of uninsured children. The single most important lesson learned from the review, according to the report, is how much estimates of the number and characteristics of uninsured children are affected by measurement error. Until progress is made in separating the measurement error from the reality of uninsurance, policy solutions will continue to be inefficient and our ability to measure our successes will continue to be limited.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Taplin, Caroline
202-690-7906

PIC ID: 7357

PERFORMER: Mathematica Policy Research, Inc.
Washington, DC