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People with endometriosis use cannabis to manage their symptoms. This study aimed to identify costs, modes of administration, product composition, and self‐reported effectiveness for those accessing medicinal cannabis in Australia. There were 192 survey responses analysed. Most (63.5%) used a 'cannabis clinic' doctor, incurring an initial consultation cost of $100–$200+ (10.2% Medicare bulk‐billed) and median cannabinoid medicine costs of $300AUD per month. Cost was a major barrier to access, necessitating reducing dosage (76.1%) and/or consuming illicit cannabis (42.9%), despite a prescription. Most (77%) medical consumers used two or more cannabis products, with delta‐9‐tetrahydrocannabinol predominant oil and flower products most frequently prescribed. [ABSTRACT FROM AUTHOR]

Objective: Lifetime Health Cover (LHC) was introduced in mid-2000 to increase participation in private health insurance that includes hospital cover (PHI-HC) and improve the risk profile of PHI-HC participants. It initially achieved both objectives, but since 2001 the PHI-HC population has aged faster than the general population. The aim of this study was to determine if the excess ageing of the PHI-HC risk pool has been due to passive age-based adverse selection, an inherent risk of LHC. This study has potential implications for the retention of LHC. Methods: A descriptive population-level analysis of publicly available administrative datasets was performed. Data relating to PHI-HC were obtained from the Australian Prudential Regulatory Authority. National population data were obtained from the Australian Bureau of Statistics. Trends in demography, PHI-HC participation rates and LHC loading payments were analysed. Results: By 2021, age-based adverse selection had returned to the pre-LHC level. Based on the available data, this was due to passive age-based adverse selection not active age-based adverse selection. Specifically, it reflected the combination of an avoidable unintended consequence of the introduction of LHC (the over-representation, in 2001, of individuals aged 45–59) and one of LHC's intended effects (incentivisation of insured individuals to retain PHI-HC). Conclusions: This study supports the retention of LHC. Nonetheless, it highlights the risk of passive age-based adverse selection created by incentivising insured individuals to retain PHI-HC in the presence of distortions in the age distribution of the PHI-HC risk pool. Early targeted interventions are required when such distortions arise. What is known about the topic? Since the introduction of Lifetime Health Cover (LHC) in mid-2000, the participation rate for private health insurance that includes hospital cover (PHI-HC) has remained relatively stable, but the PHI-HC population has aged faster than the general population. What does this paper add? This paper makes a novel distinction between 'active' and 'passive' age-based adverse selection to explain LHC's role in the excess ageing of the PHI-HC risk pool. What are the implications for practitioners? Governments need to be vigilant for the emergence of distortions in the age distribution of the PHI-HC risk pool and respond with targeted interventions to normalise the age distribution, or risk problematic passive age-based adverse selection. [ABSTRACT FROM AUTHOR]

Objectives: With elimination of the financial burden of dental services, one can expect an increase in utilization of dental services. This study aimed to investigate the effective mechanisms of financial barriers to the utilization of dental services in an Australian adult population. Methods: South Australian survey data from the Dental Care and Oral Health Study (2015) were analysed. Following the flexible mediation approach, the direct effect of income and indirect effect of income through mediators (insurance, concession card and service sector) on the outcomes (visit avoidance and treatment prevention due to the cost) were calculated. Results: Findings showed that around half of the low‐income people and one‐third of the high‐income South Australians experienced a financial burden on receiving a dental visit or service. The indirect effect of income on both outcomes of financial burden was negligible, while the direct effect was significant. By changing the potential outcome distribution to their counterfactual exposure distribution and if the mediators are drawn from their counterfactual exposure (lower/higher income) distribution, the odds of visit avoidance and treatment prevention due to the cost were almost twice (Odds Ratio: 2.13, 95% CI 1.72–2.60) and 98% (Odds Ratio: 1.98, 95% CI 1.67–2.35) than in the lower‐income individuals, respectively. Conclusions: It can be concluded that the level of household income, directly and regardless of insurance status, concession card ownership and whether the service sector was public or private, affected the financial burden on utilization of dental services. [ABSTRACT FROM AUTHOR]

Background: Hysteroscopy is a safe procedure which allows both diagnosis and management of cervical and endometrial pathology. Improving Australian women's access to outpatient hysteroscopy would improve cost efficiency and allow women a quicker recovery, negating the need for a general anaesthetic. Increasing the Medicare renumeration for outpatient hysteroscopy could incentivise provision of outpatient hysteroscopy. Aim: We sought to review the trend and current uptake of outpatient diagnostic hysteroscopy in Medicare Benefits Scheme (MBS)‐funded clinics within Australia. Materials and Methods: A retrospective review of Australian MBS data from 1 January 1993 to 31 December 2020. Results: Over the past 27 years, 1 319 909 hysteroscopies have been claimed from Medicare in Australia, with 39 958 (3.1%) claimed as an outpatient diagnostic procedure. Australian outpatient diagnostic hysteroscopy MBS item number use peaked in 1994 (5871 cases) representing 18.2% of all hysteroscopies claimed through the MBS that year. Uptake of the outpatient hysteroscopy item number rapidly declined after 1994 and in 2010, it represented 0.8% of all hysteroscopies claimed (426 of 49 618) and has remained below <0.5% from 2010 to 2020. Conclusions: The lower Medicare rebate and lack of recognition of the importance of outpatient hysteroscopy has likely been a driving factor in continuing inpatient hysteroscopy. Incentivised government funding has been successfully utilised in the UK to improve outpatient hysteroscopy access. This MBS data suggests that Australia has not progressed in outpatient hysteroscopy access and support a change in the current funding model to assist in supporting the uptake of outpatient access. [ABSTRACT FROM AUTHOR]

Objective: This study set out to present data on out-of-pocket payments for Medicare mental health services provided by general practitioners (GP), psychiatrists, clinical psychologists and other psychologists, to explore how much is spent on out-of-pocket payments for mental health; if any trends could be seen; and what variations exist across regions. Methods: We performed secondary analysis of publicly available data on Medicare-subsidised GP, allied health and specialist health care across Australia. We merged and interrogated data covering the period 2013–19 and 2019–21 to create a data set covering eight full years of Medicare mental health services, arranged by profession and by region. Results: Out-of-pocket payments for mental health care in Australia have been rising consistently over the period 2013–21, at a considerably faster rate than overall expenditure on mental health care. There is wide variation in out-of-pocket payments depending on where you live. Conclusions: The impact of out-of-pocket payments on community access to mental health care is growing. This has implications, especially in poorer communities, for access to care. This should be an important consideration taken as the Australian Government considers next steps in national mental health reform, including the Better Access Program, currently under evaluation. What is known about the topic? A$35 m is spent on Medicare mental health services every week but there has been little research on the out-of-pocket payments charged to Australians. What does this paper add? Looking at Medicare data from 2013 to 2021, this paper answers three main questions: how much are out-of-pocket payments for mental health in Australia; what trends can be seen; and what variations exist? What are the implications for practitioners? Medicare's Better Access Program is under current review and this research can help practitioners, funders and policy-makers understand the significant investment made in mental health services. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to explore policy paths towards private health insurance (PHI) reform that might reduce out-of-pocket costs, restore public confidence and allow insurers to finance value-based care. Methods: This study used thematic analysis of semi-structured interviews with informed opinion holders, including a politician, three former senior public servants and an industry lobbyist. Critical analysis of peer reviewed and grey literature was also conducted. Results: PHI regulation is contributing to unexpected out-of-pocket expenses and low-value care. Modification of existing tax incentives would be incapable of significantly increasing PHI coverage. Regulatory reform could restore confidence among policy holders by promoting value-based care, wherein health outcomes are measured and incentivised with remuneration. Conclusions: Targeted relaxation of out-of-hospital restrictions should be explored to promote value-based competition and facilitate bundled payments for chronic disease management and community services. To address out-of-pocket diagnostic and procedural costs, insurers should have more responsibility for private specialist's fees, including by financing the entire provider's bill through insurance and redirecting the Medicare Benefits Schedule fee to the insurer. What is known about the topic?: Healthcare expenditure and out-of-pocket costs have grown rapidly, while confidence and depth of coverage in private health insurance has declined, as has the fiscal appetite for expanding public financing for health care. What does this paper add?: This paper outlines the regulatory and policy factors that are contributing to low-value care and unmet expectations from insurance policy holders. It also maps the strategic terrain of the non-government health sector and considers feasible policy options for reforming the PHI industry that do not increase drawings on the public purse. What are the implications for practitioners?: An appreciation of the ongoing challenges to financing value-based care provision will inform key stakeholders, including policymakers and health service providers, as reforms are debated and implemented. [ABSTRACT FROM AUTHOR]

In many countries, health technology assessment (HTA) organizations determine the economic value of new drugs and make recommendations regarding appropriate pricing and coverage in national health systems. In the US, recent policy proposals aimed at reducing drug costs would link drug prices to six countries: Australia, Canada, France, Germany, Japan, and the UK. We reviewed these countries' methods of HTA and guidance on price and coverage recommendations, analyzing methods and guidance documents for differences in (1) the methodologies HTA organizations use to conduct their evaluations and (2) considerations they use when making recommendations. We found important differences in the methods, interpretations of HTA findings, and condition-specific carve-outs that HTA organizations use to conduct evaluations and make recommendations. These variations have ethical implications because they influence the recommendations of HTA organizations, which affect access to the drug through national insurance and price negotiations with manufacturers. The differences in HTA approaches result from the distinct political, social, and cultural contexts of each organization and its value judgments. New cost-containment policies in the US should consider the ethical implications of the HTA reviews that they are considering relying on to negotiate drug prices and what values should be included in US pricing policy. [ABSTRACT FROM AUTHOR]

Australian health policy has prioritized efforts to close the ten-year life expectancy gap between indigenous and nonindigenous Australians, a disparity largely driven by cardiovascular disease and diabetes. Because out-of-pocket spending poses a barrier to accessing medications for chronic conditions, in 2010 the Australian government reduced or eliminated medication copayments for indigenous people with chronic disease or risk factors for chronic disease. In this quasiexperimental study we found that the copayment reductions were associated with a 39 percent relative increase in the use of medications and a 61 percent reduction in out-of-pocket spending. Among indigenous Australians who qualified for the largest copayment reductions, overall use of medications increased by 156 percent--including increases of 26-109 percent in the use of lipid-lowering, hypertension, and diabetes medications. These findings suggest that Australia's novel strategy of targeted copayment reductions improved access to prescription medications among indigenous Australians, a population with a high burden of chronic conditions and marked social disadvantage. [ABSTRACT FROM AUTHOR]

Background: Current evidence suggests that preimplantation genetic testing for aneuploidy (PGT‐A) used during assisted reproductive technology improves per‐cycle live‐birth rates but cumulative live‐birth rate (CLBR) was similar to a strategy of morphological assessment (MA) of embryos. No study has assessed the cost‐effectiveness of repeated cycles with PGT‐A using longitudinal patient‐level data. Aim: To assess the cost‐effectiveness of repeated cycles with PGT‐A compared to MA of embryos in older women. Materials and Methods: Micro‐costing methods were used to value direct resource consumption of 2093 assisted reproductive technology‐naïve women aged ≥37 years undergoing up to three 'complete assisted reproductive technology cycles' (fresh plus cryopreserved embryos) with either PGT‐A or MA in an Australian clinic between 2011 and 2014. Incremental cost‐effective ratios were calculated from healthcare and patient perspectives with uncertainty assessed using non‐parametric bootstrap methods. Cost‐effectiveness acceptability curves were constructed to evaluate the probability of PGT‐A being cost‐effective over a range of willingness‐to‐pay thresholds. Results: The CLBR and mean healthcare costs per patient were 30.90% and $22 962 for the PGT‐A group, and 26.77% and $21 801 for the MA group, yielding an incremental cost‐effective ratio of $28 103 for an additional live birth with PGT‐A. At a willingness‐to‐pay threshold of $50 000 and above, there is more than an 80% probability of PGT‐A being cost‐effective from the healthcare perspective and a 50% likelihood from a patient perspective. Conclusion: This is the first study to use real‐world patient‐level data to assess the cost‐effectiveness of PGT‐A in older women from the healthcare and patient perspectives. The findings contribute to the ongoing debate on the role of PGT‐A in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Disease management programmes may improve quality of care, improve health outcomes and potentially reduce total healthcare costs. To date, only one very large population-based study has been undertaken and indicated reductions in hospital admissions > 10%.Objective: We sought to confirm the effectiveness of population-based disease management programmes. The objective of this study was to evaluate the relative impact on healthcare utilisation and cost of participants the Costs to Australian Private Insurance - Coaching Health (CAPICHe) trial.Design: Parallel-group randomised controlled trial, intention-to-treat analysis SETTING: Australian population PARTICIPANTS: Forty-four thousand four hundred eighteen individuals (18-90 years of age) with private health insurance and diagnosis of heart failure, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes, or low back pain, with predicted high cost claims for the following 12 months.Intervention: Health coaching for disease management from Bupa Health Dialog, vs Usual Care.Main Outcome Measures: Total cost of claims per member to the private health insurer 1 year post-randomisation for hospital admissions, including same-day, medical and prostheses hospital claims, excluding any maternity costs. Analysis was based on the intent-to-treat population.Results: Estimated total cost 1 year post-randomisation was not significantly different (means: intervention group A$4934; 95% CI A$4823-A$5045 vs control group A$4868; 95% CI A$4680-A$5058; p = 0.524). However, the intervention group had significantly lower same-day admission costs (A$468; 95% CI A$454-A$482 vs A$508; 95% CI A$484-A$533; p = 0.002) and fewer same-day admissions per 1000 person-years (intervention group, 530; 95% CI 508-552 vs control group, 614; 95% CI 571-657; p = 0.002). Subgroup analyses indicated that the intervention group had significantly fewer admissions for patients with COPD and fewer same-day admissions for patients with diabetes.Conclusions: Chronic disease health coaching was not effective to reduce the total cost after 12 months of follow-up for higher risk individuals with a chronic condition. Statistically significant changes were found with fewer same-day admissions; however, these did not translate into cost savings from a private health insurance perspective. [ABSTRACT FROM AUTHOR]

High-income countries are grappling with the challenge of caring for aging populations, many of whose members have chronic illnesses and declining capacity to manage activities of daily living. The 2017 Commonwealth Fund International Health Policy Survey of Older Adults in eleven countries showed that US seniors were sicker than their counterparts in other countries and, despite universal coverage under Medicare, faced more financial barriers to health care. The survey's findings also highlight economic hardship and mental health problems that may affect older adults' health, use of care, and outcomes. They show that in some countries, one in five elderly people have unmet needs for social care services--a gap that can undermine health. New to the survey is a focus on the "high-need" elderly (those with multiple chronic conditions or functional limitations), who reported high rates of emergency department use and care coordination failures. Across all eleven countries, many high-need elderly people expressed dissatisfaction with the quality of health care they had received. [ABSTRACT FROM AUTHOR]

Objectives There are few studies of dental service expenditure in Australia. Although dental insurance status is strongly associated with a higher probability of dental visiting, some studies indicate that there is little variation in expenditure by insurance status among those who attend for care. Our objective was to assess the overall impact of insurance on expenditures by modelling the association between insurance and expenditure accounting for variation in the probability of incurring expenses, that is dental visiting. Methods A sample of 3000 adults (aged 30-61 years) was randomly selected from the Australian electoral roll. Dental service expenditures were collected prospectively over 2 years by client-held log books. Questionnaires collecting participant characteristics were administered at baseline, 12 months and 24 months. Unadjusted and adjusted ratios of expenditure were estimated using marginalized two-part log-skew-normal models. Such models accommodate highly skewed data and estimate effects of covariates on the overall marginal mean while accounting for the probability of incurring expenses. Results Baseline response was 39%; of these, 40% ( n = 438) were retained over the 2-year period. Only participants providing complete data were included in the analysis ( n = 378). Of these, 68.5% were insured, and 70.9% accessed dental services of which nearly all (97.7%) incurred individual dental expenses. The mean dental service expenditure for the total sample (those who did and did not attend) for dental care was AUS$788. Model-adjusted ratios of mean expenditures were higher for the insured (1.61; 95% CI 1.18, 2.20), females (1.38; 95% CI 1.06, 1.81), major city residents (1.43; 95% CI 1.10, 1.84) and those who brushed their teeth twice or more a day (1.50; 95% CI 1.15, 1.96) than their respective counterparts. Conclusion Accounting for the probability of incurring dental expenses, and other explanatory factors, insured working-aged adults had (on average) approximately 60% higher individual dental service expenditures than uninsured adults. The analytical approach adopted in this study is useful for estimating effects on dental expenditure when a variable is associated with both the probability of visiting for care, and with the types of services received. [ABSTRACT FROM AUTHOR]

For decades, public satisfaction with the health care system has been lower in the United States than in other high-income countries. To better understand the distinctive nature of US health system satisfaction, we compared the determinants of satisfaction with the health system in the United States to those in seventeen other high-income countries by applying regression decomposition methods to survey data collected in the period 2011-13. We found that concerns related to "accessing most-preferred care" (the extent to which people feel that they can access their top preferences at a time of need) were more important to satisfaction in the United States than in other high-income countries, while the reverse was true for satisfaction with recent interactions with the health system. Differences among US socioeconomic groups in survey responses regarding access to most-preferred care suggest that wide variation in insurance coverage and generosity may play a role in these differences. While reductions in the uninsured population and the movement toward minimum health plan standards could help address some concerns about access to preferred care, our results raise the possibility of public backlash as market forces push plans toward more restricted access and higher cost sharing. [ABSTRACT FROM AUTHOR]

Abstract: Emergency medicine was once exclusively provided in public hospitals in Australia, but now over half a million consultations per annum are in private (7% total emergency consultations). Private EDs have excess capacity and are staffed by senior doctors (majority FACEM) with open access to investigations and broad specialist inpatient services. Public EDs struggle with rising attendances and overcapacity. Private hospitals have high levels of patient satisfaction and aim to optimise service provision. A major barrier to private ED attendances is out‐of‐pocket costs. Insurers deem private EDs outpatient services and therefore do not contribute any funding to these attendances. Additionally state governments provide no funding while Medicare items cover only 10–15% of costs. Out‐of‐pocket consultation costs to patients vary nationally ($110–$480) but never cover the full cost of providing services. Patients may also pay out‐of‐pocket costs for investigations. Private EDs can provide many benefits to patients and the community. Patients can see senior doctors immediately (at less cost per patient than public EDs). Demand can be directed away from resource‐poor public EDs. Private EDs could also provide extra surge capacity during disasters. There is a need for further strong advocacy for private emergency medicine at many levels, particularly regarding the lack of funding. Stakeholder relationships should be strengthened. Research and education about decision‐making in the choice between public and private ED attendance should be encouraged, particularly regarding paramedic advice to patients. Finally, patients who have purchased private insurance should be able to utilise it during evaluation of an acute illness. [ABSTRACT FROM AUTHOR]

Objective. There are many medicines listed on the Australian Pharmaceutical Benefits Scheme (PBS) in which point of sale price is less than the level of the general patient co-payment. In these circumstances, the patient covers the total cost of the medicine from their own pocket with no government subsidy. The aim of the present study was to compare the consumer prices of under general co-payment prescription medicines between banner group pharmacies with open discounting policies and community pharmacies without; and to assess the impact of the April 2012 PBS price disclosure policies on the discounts offered. Methods. The consumer prices of 31 under co-payment medicines were collected from banner group pharmacy websites and individual pharmacies both before and after April 2012. PBS maximum prices were obtained from the PBS website. Absolute and relative price differences between PBS and pharmacy groups were calculated. Results. Before April 2012, banner group pharmacies provided discounts to patients of around 40% per prescription, whereas other pharmacies provided discounts of around 15%. Total price savings were on average $9 per prescription at banner group pharmacies and $3.50 at other pharmacies. Percentage discounts did not change greatly after April 2012, when price decreases occurred on the PBS. Conclusions. Banner group pharmacies with pricing strategies are able to provide greater discounts to patients compared with other pharmacies. Community pharmacies still have the ability to provide substantial discounts after the April 2012 price reductions. [ABSTRACT FROM AUTHOR]

This paper sets out to explore the Australian instance of a significant international problem: Intergenerational solidarity and the willingness of younger generations to support the future care of older people. It draws on Bengston's intergenerational solidarity theory, in particular his conception of normative solidarity relative to filial obligations, to analyse data from the Australian Survey of Social Attitudes. This data demonstrates evidence of intergenerational solidarity at the policy level and a need for a continued role for government in the provision of residential care, insurance schemes, and the payment of income to full time and occasional carers. At the family level there is less support for the role of adult children in the payment of formal care or the provision of informal care. There is also a significant difference between men and women concerning the direct provision of informal care to ageing parents. Suggestions for future research are highlighted. [ABSTRACT FROM AUTHOR]

The United States is in the midst of the most sweeping health insurance expansions and market reforms since the enactment of Medicare and Medicaid in 1965. Our 2013 survey of the general population in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-found that US adults were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Signaling the lack of timely access to primary care, adults in the United States and Canada reported long waits to be seen in primary care and high use of hospital emergency departments, compared to other countries. Perhaps not surprisingly, US adults were the most likely to endorse major reforms: Three out of four called for fundamental change or rebuilding. As US health insurance expansions unfold, the survey offers benchmarks to assess US progress from an international perspective, plus insights from other countries' coverage-related policies. [ABSTRACT FROM AUTHOR]

Two decades ago Australia introduced an assessment of value as a prerequisite for adding new medicines to its national drug formulary. Australia's program-a "fourth hurdle" process after a drug is assessed for safety, efficacy, and quality-stands in stark contrast to the situation in the United States, where comparing the clinical and economic value of a proposed new drug to those of existing ones only rarely plays a role in the drug coverage determination process. This article describes the role that Australia's Pharmaceutical Benefits Advisory Committee, a statutory independent expert committee, plays in determining which new drugs the government will help pay for in the nation's pharmaceutical benefit program. The program does not directly control drug prices or ration prescription drugs-policy options that are widely opposed in the United States. Australia's program supports patients' access to important, innovative medications deemed to be cost-effective. The US system could benefit if policy makers examined Australia's experience and adopted a comparative clinical and value review suited to the US political and economic landscape. [ABSTRACT FROM AUTHOR]

This 2010 survey examines the insurance-related experiences of adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United States, and the United Kingdom. The countries all have different systems of coverage, ranging from public systems to hybrid systems of public and private insurance, and with varying levels of cost sharing. Overall, the study found significant differences in access, cost burdens, and problems with health insurance that are associated with insurance design. US adults were the most likely to incur high medical expenses, even when insured, and to spend time on insurance paperwork and disputes or to have payments denied. Germans reported spending time on paperwork at rates similar to US rates but were well protected against out-of-pocket spending. Swiss out-of-pocket spending was high, yet few Swiss had access concerns or problems paying bills. For US adults, comprehensive health reforms could lead to improvements in many of these areas, including reducing differences by income observed in the study. [ABSTRACT FROM AUTHOR]

In response to declining insurance coverage and adverse selection, in May 2015, Ireland introduced lifetime community rating (LCR) of health insurance premiums to encourage take-up of health insurance at younger ages. LCR requires that late-entry premium loadings be applied to those, aged 35 and over, taking out health insurance for the first time. This analysis exploits quasi-experimental difference-in-differences methods to estimate the effect of LCR regulations on insurance take-up, controlling for potentially confounding factors. Findings reveal that the introduction of LCR increased coverage rates for those aged 35–69 by approximately 2.5 percentage points (p < 0.01). However, the impact on coverage was largely concentrated in the 35–54 age cohort. Relative to underlying plan coverage rates, take-up was proportionately greatest for low-cover plans. Ireland is the second country to introduce late-entry premium loadings to its voluntary health insurance market, following Australia in 2000. This analysis adds to the current evidence base and improves understanding of consumer response to these regulations. The introduction of LCR has encouraged insurance take-up by those who may have otherwise postponed take-up to older ages contributing to a reversal in declining overall coverage trends, at least initially. However, the purchase of cheaper plans by relatively younger consumers could be contributing to risk segmentation within the market. Moreover, these cheaper insurance plans tend to offer limited benefits and consumers may still face significant out-of-pocket costs to access private care. • Ireland is only the second country to introduce late-entry premium loadings. • These regulations increased health insurance coverage rates. • Coverage increases were concentrated in those aged 35-54. • Many consumers responded through purchase of low-cover plans. [ABSTRACT FROM AUTHOR]