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Objective: To estimate the long-term effects of cancer survivorship on the employment of older workers.Data Sources: Primary data for 504 subjects who were 55-65 in 2002 and were working when diagnosed with cancer in 1997-1999, and secondary data for a comparison group of 3,903 similarly aged workers in the Health and Retirement Study (HRS) in 2002.Study Design: Three employment outcomes (working, working full time, usual hours per week) were compared between the two groups. Both Probit/Tobit regressions and propensity score matching were used to adjust for potentially confounding differences between groups. Sociodemographic characteristics, baseline employment characteristics, and the presence of other health conditions were included as covariates.Data Collection Methods: Four telephone interviews were conducted annually with cancer survivors identified from tumor registries at four large hospitals in Pennsylvania and Maryland. Many of the questions were taken from the HRS to facilitate comparisons.Principal Findings: Cancer survivors of both genders worked an average of 3-5 hours less per week than HRS controls. For females, we found significant effects of survivorship on the probability of working, the probability of working full-time, and hours. For males, survivorship affected the probability of full-time employment and hours without significantly reducing the probability of working. For both genders, these effects were primarily attributable to new cancers. There were no significant effects on the employment of cancer-free survivors.Conclusions: Survivors with recurrences or second primary tumors may particularly benefit from employment support services and workplace accommodation. Reassuringly, any long-term effects on the employment of cancer-free survivors are fairly small. [ABSTRACT FROM AUTHOR]

Background: Studies of cancer survivors usually report positive correlations between income and health-related quality of life (QoL). These correlations cannot necessarily be interpreted as income disparities because earnings and income are affected by health, as well as the reverse.Objectives: The goal of this study was to quantify income disparities in QoL among cancer survivors by using instrumental variables (IV) to assess and, if necessary, correct for reverse causality.Methods: We constructed an instrumental variable for income from home ownership, sources of unearned income, marital status at diagnosis, and spousal characteristics. Then, we examined income's effect on QoL in regressions controlling for other clinical and demographic predictors of QoL. The data were from interviews in 2002 with a cohort of cancer survivors who were 25 to 62 years of age when diagnosed during 1997 to 1999.Measures: The Functional Assessment of Cancer Therapy-General (FACT-G) and the SF-12 measured QoL in multiple domains. Questions adapted from the Health and Retirement Study ascertained the ratio of annual family income to the poverty threshold in 2001.Results: Endogeneity tests were sensitive to assumptions of linearity for the income-QoL relationship and the choice of QoL measure. Consistently estimated income disparities were significant in all QoL models. The income elasticity of QoL ranged from 2% to 10%.Conclusions: There are income-related disparities in the QoL of cancer survivors that cannot be explained away by the effect of health on earnings. High-income patients are not only more likely to survive cancer, but they enjoy better QoL as survivors. [ABSTRACT FROM AUTHOR]

Disabled workers who start receiving Social Security Disability Income (SSDI) must wait twenty-four months to qualify for Medicare. Legislation introduced in Congress would eliminate this waiting period, to guarantee that people with disabilities severe enough to qualify for SSDI will not be uninsured. We provide a longitudinal view of Medicare enrollment before age sixty-five by following a national sample of people ages 55-64. One person in six was covered by Medicare before turning sixty-five. A quarter of new enrollees were uninsured during the waiting period. There were great disparities in reliance on Medicare and coverage in the waiting period. [ABSTRACT FROM AUTHOR]

While geographic disparities in cancer treatment are documented, little research has investigated patients' willingness to travel longer distances for treatment at higher-quality hospitals. Even fewer studies have compared metropolitan and non-metropolitan patients on this dimension. Using population-based data from the Appalachian counties of four states, we identified all hospitals within a plausible driving distance of each newly diagnosed colon cancer patient and estimated conditional logit models of hospital choices for cancer surgery. Two sets of important findings emerged. First, both metropolitan and non-metropolitan patients chose higher-quality over lower-quality hospitals, and were willing to travel farther to use high-quality facilities. Second, non-metropolitan patients were not willing to travel farther than their metropolitan counterparts to hospitals that were more desirable along most dimensions, but non-metropolitan patients were willing to travel farther to high-volume hospitals. These findings show how travel distances to high-quality hospitals contribute to geographic disparities in colon cancer treatment.

We studied differences in access to large or accredited cancer programs as a possible explanation for geographic disparities in adherence to the national guideline on lymph node assessment for Stages I to III colon cancer. State cancer registries were linked with Medicare claims of patients diagnosed from 2006 to 2008 from Appalachian counties of four states. Metropolitan and nonmetropolitan patients differed on adherence, proximity to high-volume or accredited hospitals, and hospital type. We modeled effects of hospital type on adherence with ordinary least squares and instrumental variables (instrumenting for hospital type with relative distance). The evidence was strongest for improved adherence in high-volume hospitals for nonmetropolitan patients. We estimate that roughly 100 deaths might be prevented over 5 years among each year's incident cases if the nonmetropolitan disparity in hospital volume were eliminated nationally. We conclude that regionalization or targeting smaller hospitals would improve adherence in nonmetropolitan areas, but also argue for improving adherence generally., (© The Author(s) 2015.)

Medicaid churning--the constant exit and reentry of beneficiaries as their eligibility changes--has long been a problem for both Medicaid administrators and recipients. Churning will continue under the Affordable Care Act because, despite new federal rules, Medicaid eligibility will continue to be based on current monthly income. We developed a longitudinal simulation model to evaluate four policy options for modifying or extending Medicaid eligibility to reduce churning. The simulations suggest that two options--extending eligibility either to the end of a calendar year or for twelve months after enrollment--would be the most effective methods for reducing churning. The other options--a three-month extension or eligibility based on projected annual income--would reduce churning to a lesser extent. States should consider implementation of the option that best balances costs while improving access to coverage and, thereby, the health of Medicaid enrollees., (Project HOPE—The People-to-People Health Foundation, Inc.)

Purpose: The mortality rate of laryngeal cancer has been trending downward with the use of more effective surgical, radiation, and systemic therapies. Although the best treatment for this disease is not entirely clear, there is a growing consensus on the value of primary radiotherapy as an organ preservation strategy. This study examines urban-rural differences in the use of radiotherapy as the primary treatment for early stage laryngeal cancer in Pennsylvania., Experimental Design: The sample was drawn from the Pennsylvania tumor registry, which lists 2,437 laryngeal cancer patients diagnosed from 2001 to 2005. We selected 1,705 adults with early stage squamous cell carcinoma of the larynx for our analysis. Demographic data and tumor characteristics were included as control variables in multivariate analyses. Rurality was assigned by ZIP code of patient residence., Results: Controlling for demographic and clinical factors, rural patients were less likely than urban patients to receive radiotherapy as the primary treatment modality for early stage larynx cancer (OR 0.740, 95% CI 0.577-0.949, P = .0087). No other associations between rural status and treatment choice were statistically significant., Conclusions: Relatively fewer rural patients with larynx cancer are treated primarily with radiation therapy. Further investigations to describe this interaction more thoroughly, and to see if this observation is found in larger population data sets, are warranted., (© 2014 National Rural Health Association.)

Existing studies of the labor market status of cancer survivors have focused on the extent to which cancer disrupts the employment of individuals who were working when diagnosed with cancer. We examine how surviving cancer affects labor market entry and usual hours of work among females aged 28 to 54 years who were not working when first diagnosed. We find that prime-age females have employment rates 2 to 6 years after diagnosis that are 12 percentage points lower than otherwise similar women who were initially out of the labor force, full-time employment rates that are 10 percentage points lower, and usual hours of work that are 5 hours per week lower. These estimates are somewhat larger than estimates for prime-age women employed at the time of diagnosis and highlight the importance of considering nonworking females when assessing the economic and psychosocial burden of cancer.

Background: Access to health care, particularly effective primary and secondary preventive care, is critical for cancer survivors, in order to minimize the adverse sequelae of cancer and its treatment., Purpose: The goal of the study was to evaluate the association between cancer survivorship and access to primary and preventive health care., Methods: Cancer survivors (n=4960) and individuals without a cancer history (n=64,431) aged ≥ 18 years, from the 2008-2010 Medical Expenditure Panel Survey (MEPS), were evaluated. Multiple measures of access and preventive services use were compared. The association between cancer survivorship and access and preventive services was evaluated with multivariate logistic regression models, stratified by age group (18-64 years and ≥ 65 years), controlling for the effects of age, gender, race/ethnicity, education, marital status, and comorbidities. Data were analyzed in 2013., Results: Cancer survivors aged ≥ 65 years had equivalent or greater access and preventive services use than individuals without a cancer history, in adjusted analyses. However, among those aged 18-64 years with private health insurance, cancer survivors were more likely than other individuals to have a usual source of care and to use preventive services, whereas uninsured or publicly insured cancer survivors were generally less likely to have a usual source of care and to use preventive services than were uninsured or publicly insured adults without a cancer history., Conclusions: Although access and preventive care use in cancer survivors is generally equivalent or greater compared to that of other individuals, disparities for uninsured and publicly insured cancer survivors aged 18-64 years suggest that improvements in survivor care are needed., (Published by Elsevier Inc.)

Changes in individual or family circumstances cause many Americans to experience gaps and transitions in public and private health insurance. Using data from the 2004-2007 Survey of Income and Program Participation, this article updates earlier analyses of insurance gaps and transitions. Eighty-nine million people (one third of nonelderly Americans) were uninsured for at least 1 month during those 4 years. Approximately 23 million lost insurance more than once. The analyses call attention to the continuing instability and insecurity of health insurance, can inform implementation of national reforms, and establish a recent baseline that will be helpful in evaluating the reforms' effects on coverage stability.

Objectives: This study aimed to describe national utilization of psychotropic medications by adult cancer survivors in the USA and to estimate the extra use of psychotropic medications that is attributable to cancer survivorship., Methods: Prescription data for 2001-2006 from the Medical Expenditure Panel Survey (MEPS) were linked to the data identifying cancer survivors from the National Health Interview Survey, the MEPS sampling frame. The sample was limited to adults 25 years of age and older. Propensity score matching was used to estimate the effects of cancer survivorship on utilization of psychotropic medications by comparing cancer survivors and other adults in MEPS. Utilization was measured as any use during a calendar year and the number of prescriptions purchased (including refills). Analyses were stratified by gender and age, distinguishing adults younger than 65 years from those 65 years and older., Results: Nineteen percent of cancer survivors under age 65 years and 16% of survivors age 65 years and older used psychotropic medications. Sixteen percent of younger survivors used antidepressants, 7% used antianxiety medications. For older survivors, utilization rates for these two drug types were 11% and 7%, respectively. The increase in any use attributable to cancer amounted to 4-5 percentage points for younger survivors (p < 0.05) and 2-3 percentage points for older survivors (p < 0.05), depending on gender., Conclusion: Increased use of psychotropic medications by cancer survivors, compared with other adults, suggests that survivorship presents ongoing psychological challenges., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: The purpose of this research was to estimate employment effects for spouses of cancer survivors who were working at the time of the cancer diagnosis., Methods: Spouses of cancer survivors were drawn from the Penn State Cancer Survivor Survey. Comparable spouses of individuals without cancer were drawn from the Panel Survey of Income Dynamics. The final sample included 827 spouses of cancer survivors (542 husbands, 285 wives) and 2,766 spouses of individuals without cancer (1,459 husbands, 1,307 wives). Three employment outcomes were studied 2-6 years after diagnosis: whether working, whether working full time (35+ hours per week), and usual hours per week. We used propensity scores to match cases to controls 3:1., Results: Wives of cancer survivors had a lower probability (-7.5 percentage points) of being employed 2-6 years after diagnosis (p  =  0.036). They were slightly more likely to be working full time, while averaging 1.1 fewer hours per week overall, but these effects were not statistically significant. Cancer's effect on husbands was not significant for any of the employment outcomes. However, if survivor wives and husbands were working at follow-up, they had more than twice the odds of working full-time (wives OR = 2.18, p  =  0.0004; husbands OR = 2.65, p  =  0.012) and worked more hours per week than other spouses (wives 1.9, p  =  0.041; husbands 1.5, p  =  0.04)., Conclusions: The implications to cancer survivors and their spouses of these results is that the employment of survivor spouses, especially of wives, is somewhat reshaped by cancer in the medium to long run. However, there is little or no effect on aggregate hours worked by spouses who were employed at diagnosis.

Background: To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged <65 years. Most studies of expenditures for cancer survivors in this age group have been based on the Medical Expenditure Panel Survey (MEPS) and were limited to "affected survivors.", Methods: MEPS expenditure data for 2001 to 2007 were linked to data identifying all survivors from the National Health Interview Survey (NHIS), which is the MEPS sampling frame. The sample was comprised of adults ages 25 to 64 years. Propensity-score matching was used to estimate the effects of cancer on average total and out-of-pocket expenditures for all services and separately for prescriptions. Probit models were used to estimate effects on the probability of exceeding different expenditure thresholds., Results: Mean annual expenditures on all services in 2007 were $16,910 ± $3911 for survivors who were newly diagnosed with cancer, $7992 ± $972 for survivors who had been diagnosed in previous years, and $3303 ± $103 for other adults. Fifty-three percent of survivors were not identified in MEPS but only by linking to NHIS. Expenditures for all survivors averaged approximately $9300 compared with $13,600 for "affected survivors." For previously diagnosed survivors, the increase in mean expenditures attributable to cancer was approximately $4000 to $5000 annually. On average, relatively little of the increase was paid out of pocket, but cancer nearly doubled the risk of high out-of-pocket expenditures., Conclusions: Previous MEPS analyses overstated average expenditures for all survivors. Nevertheless, the current results indicated that the increase in expenditures attributable to cancer is substantial, even for longer term survivors, and that cancer increases the relative risk of high out-of-pocket expenditures., (Copyright © 2010 American Cancer Society.)

We compare employment and usual hours of work for prime-age cancer survivors from the Penn State Cancer Survivor Survey to a comparison group drawn from the Panel Study of Income Dynamics using cross-sectional and difference-in-differences regression and matching estimators. Because earlier research has emphasized workers diagnosed at older ages, we focus on employment effects for younger workers. We find that as long as two to six years after diagnosis, cancer survivors have lower employment rates and work fewer hours than other similarly aged adults., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children's Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.

This study examined the effect of job-related health insurance on employment transitions (labor force exits, reductions in hours, and job changes) of older working cancer survivors. Using multivariate models, we compared longitudinal data for the period 1997-2002 from the Penn State Cancer Survivor Study to similar data for workers with no cancer history in the Health and Retirement Study, who were also ages 55 to 64 at follow-up. The interaction of cancer survivorship with health insurance at diagnosis was negative and significant in predicting labor force exits, job changes, and transitions to part-time employment for both genders. The differential effect of job-related health insurance on the labor market dynamics of cancer survivors represents an additional component of the economic and psychosocial burden of cancer on survivors.

Purpose/objectives: To assess dietary supplement use and its association with demographic and health-related characteristics among cancer survivors and to investigate differences in supplement use patterns by cancer site., Design: A cross-sectional survey., Setting: Computer-assisted telephone survey., Sample: 1,233 adult (ages 30-69) survivors participating in the Penn State Cancer Survivor Study who underwent an interviewer-administered questionnaire., Methods: Descriptive statistics with multivariate logistic regression to determine demographic, disease, and health-related predictors of supplement use., Main Research Variables: Use of dietary supplements and types of supplements taken., Findings: Supplement use ranged from 50% among blood cancer survivors to 85% among melanoma skin cancer survivors, with an overall prevalence rate of 73%. Multivariate logistic regression revealed statistically significant associations (p values < 0.05) between supplement use and older age (>or= age 50), higher levels of education and physical activity, female gender, lower body mass index, and white ethnicity., Conclusions: Overall, a wide variety of supplements were reported, although multivitamins, calcium and vitamin D combinations, and antioxidant vitamin combinations were the most prevalent. Seventy-eight percent of supplement users took more than one supplement., Implications for Nursing: The findings support continued efforts by oncology nurses to identify the types of supplements cancer survivors are using. Nurses should caution against the use of individual supplements as well as combinations of different supplements containing nutrient quantities above recommended daily intake levels. Furthermore, oncology nurses and other healthcare professionals should be receptive to questions and prepared to initiate conversations with patients about their use of dietary supplements.

Objective: To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care., Data Sources: Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample (n=6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs)., Study Design: Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates., Principal Findings: Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods., Conclusion: These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.

The long-term effects of cancer and its treatment on employment and productivity are a major concern for the 40% of cancer survivors in the U.S. who are working age. This study's objectives were (1) to quantify the increase in work disability attributable to cancer in a cohort of adult survivors who were an average of 46 months post-diagnosis and (2) to compare disability rates in cancer survivors to individuals with other chronic conditions. Data from the Penn State Cancer Survivor Study (PSCSS) and the Health and Retirement Study (HRS) were compared. The PSCSS sample included 647 survivors age 55-65, diagnosed at four medical centers in Pennsylvania and Maryland. There were 5988 similarly aged subjects without cancer in the HRS. Adjusted odds ratios for work disability were estimated for cancer survivorship, heart disease, stroke, diabetes, lung disease, and arthritis/rheumatism with multivariate logistic regression. Even for cancer-free survivors, the adjusted disability rate was significantly higher in comparison to adults with no chronic conditions (female OR = 1.94; male OR = 1.89). There were few significant differences between disability rates for cancer and other conditions. The elevated disability rate is another argument for viewing cancer survivorship as a chronic condition potentially requiring a broad range of psychosocial services.

The report on cancer survivorship recently released by the Institute of Medicine called on providers to become familiar with the employment rights of survivors, to offer them information about employment rights and programs, and to help minimize the adverse effects of cancer on employment. This review is designed to help providers respond to the Institute of Medicine's recommendations by describing relevant employment and health insurance protections, nationally accessible services and information sources for survivors, functional limitations that may affect survivors' work, and a variety of rehabilitation services that may be helpful for survivors with disabling residual effects of cancer and its treatment. It also suggests directions for further efforts on the part of public and private cancer organizations, researchers, and clinicians to address the employment concerns of survivors.

This article examines the effect of parents' Medicaid status on the use of preventive health services by young children. Using data from the 1996 Medical Expenditure Panel Survey (MEPS), we analyzed a logit model for receipt of any well-child visits (WCVs) that compared three groups of low-income children. The three groups, defined by the joint insurance status of children and their parents, involved Medicaid pairs (both the child and the parent had Medicaid throughout the year), mixed pairs (the child had Medicaid and the parent was uninsured), and uninsured pairs (both child and parent were uninsured). Medicaid coverage for children was positively associated with receipt of any WCVs. However, the utilization effect of Medicaid coverage for children was significantly larger when the parent was also on Medicaid instead of being uninsured. Considering uninsured children with uninsured parents in 1996, enrolling only the children in Medicaid would have increased the percentage with WCVs from 29 to 43 percent according to simulations with the logit model. If the parents were enrolled in Medicaid as well, the percentage of children with any WCVs would have increased to 67 percent.

Background: Employment and work-related disability were investigated in a cohort of adult cancer survivors who were working when they were diagnosed from 1997 to 1999 with a variety of cancers. Employment from the time of diagnosis through the early years of survivorship was studied, self-reported effects of cancer survival on disability and employment were quantified, and risk factors associated with cancer-related disability and withdrawal from employment were identified., Methods: One thousand four hundred thirty-three cancer survivors were interviewed by telephone from 1 year to nearly 5 years after diagnosis. They were asked retrospectively about employment from the time of diagnosis to follow-up and about work-related disability at follow-up. They also were asked whether disabilities or reasons for quitting work were cancer-related. Return to work and quitting work were projected over time in a life-table analysis. Risk factors were identified from logit analyses., Results: One of five survivors reported cancer-related disabilities at follow-up. Half of those with disabilities were working. A projected 13% of all survivors had quit working for cancer-related reasons within 4 years of diagnosis. More than half of survivors quit working after the first year, when three-quarters of those who stopped for treatment returned to work. Survivors of central nervous system, head and neck, and Stage IV blood and lymph malignancies had the highest adjusted risk of disability or quitting work., Conclusions: Cancer survival sometimes has long-term effects on employment and the ability to work. Employment outcomes can be improved with innovations in treatment and with clinical and supportive services aimed at better management of symptoms, rehabilitation, and accommodation of disabilities.

This study assesses the stability of Americans' health insurance status over a four-year period. Relatively few Americans were continuously uninsured for the four years 1996 to 1999, but a sizable number of the uninsured lacked a stable source of coverage. At least as many people were repeatedly uninsured as experienced a single gap in otherwise stable coverage. Given these dynamics, policymakers should think of "uninsured" as referring not to people, but rather to gaps in coverage over time. Reforms that stop short of universal coverage should be evaluated in terms of their likely effects on the continuity and stability of coverage.

This article provides a systematic evaluation of the options for incremental health insurance reforms aimed at older Americans nearing age sixty-five. It presents three basic arguments for giving special consideration to this age group: (1) early retirement and its effect on access to employer insurance; (2) changes in health and health care expenses associated with increasing age; (3) the vulnerability to unexpected economic or health "shocks" that will affect people throughout their retirement. The analysis of policy options begins by specifying criteria for evaluating alternative approaches to reform. The proposed criteria emphasize that reforms for this age group should be designed to fit with other financial plans and decisions made during such a transitional stage of life. Policy options should be judged according to fundamental goals such as equity and efficiency, not simply ranked according to the number of uninsured who will gain coverage. After offering a comprehensive catalog and evaluation of available options, the analysis identifies and discusses a preferred approach-which preserves choices while offering universal and subsidized access to Medicare before age sixty-five.

This evaluation tested if Consumer Assessment of Health Plans Study (CAHPS) information on plan performance affected health plan choices by new beneficiaries in Iowa Medicaid. New cases entering Medicaid in selected counties during February through May 2000 were assigned randomly to experimental or control groups. The control group received standard Medicaid enrollment materials, and the experimental group received these materials plus a CAHPS report. We found that CAHPS information did not affect health plan choices by Iowa Medicaid beneficiaries, similar to previously reported findings for New Jersey Medicaid. However, it did affect plan choice in an earlier laboratory experiment. The value of this information may be limited to a subset of receptive consumers who actively study information received, even then only when (1) ratings of available plans differ greatly, (2) ratings differ from prior beliefs about plan quality, and (3) reports are easy to understand.

Objective: To assess the effects of CAHPS health plan performance information on plan choices and decision processes by New Jersey Medicaid beneficiaries., Data Sources/study Setting: The study sample was a statewide sample of all new Medicaid cases that chose Medicaid health plans during April 1998. The study used state data on health maintenance organization (HMO) enrollments and survey data for a subset of these cases., Study Design: An experimental design was used, with new Medicaid cases randomly assigned to experimental or control groups. The experimental group received a CAHPS report along with the standard enrollment materials, and the control group did not., Data Collection: The HMO enrollment data were obtained from the state in June 1998, and evaluation survey data were collected from July to October 1998., Principal Findings: No effects of CAHPS information on HMO choices were found for the total sample. Further examination revealed that only about half the Medicaid cases said they received and read the plan report and there was an HMO with dominant Medicaid market share but low CAHPS performance scores. The subset of cases who read the report and did not choose this dominant HMO chose HMOs with higher CAHPS scores, on average, than did those in an equivalent control group., Conclusions: Health plan performance information can influence plan choices by Medicaid beneficiaries, but will do so only if they actually read it. These findings suggest a need for enhancing dissemination of the information as well as further education to encourage informed choices.

This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing information about quality did not significantly influence the choice between Original Medicare and a health maintenance organization (HMO), but did affect the choice of HMO. Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality. Furthermore, beneficiaries choosing among HMOs were not inclined to select a low-cost HMO, even when it was rated higher in quality. Implications for policy are discussed.

Incremental reforms to expand health coverage among older Americans are justified by medical spending that increases with age and enrollment in employer insurance that decreases with age. Older Americans are also at risk of unexpected changes in health, access to health insurance, and earnings that could leave them poorly positioned financially for their retirement years. We propose offering universal access to Medicare at a community-rated premium, with premium vouchers for those with a history of low lifetime earnings and tax-preferred savings accounts to help everyone with the increased cost of insurance at older ages. These subsidies are available for coverage obtained from sources other than Medicare. We would set the eligibility age for the buy-in at 62. However, because enrollment in employer insurance does not drop precipitously at age 62, we regard the eligibility age as an adjustable design element that could resize the program to fit political and budgetary constraints.

Many consumers are offered two or more employer-sponsored health insurance plans, and competition among health plans for subscribers is promoted as a mechanism for balancing health care costs and quality. Yet consumers may not receive the information necessary to make informed health plan choices. This study tests the effects on health plan choice of providing supplemental decision-support materials to inform consumers about expected health plan costs. Our main finding is that such information induces consumers to bear more risk, especially those in relatively good health. Thus our results suggest that working-age, privately insured consumers currently may be over-insuring for medical care.

Recent Medicare buy-in proposals agree on setting eligibility at age sixty-two but disagree on linking eligibility to loss of employer insurance or ability to pay. We examine arguments for targeting incremental coverage for older Americans in these ways. While access to retiree health insurance is declining, we question whether targeting loss of employer insurance can address many older Americans' insurance problems. Furthermore, focusing on persons ages sixty-two to sixty-four misses a large group of persons in poor health with limited resources. Efforts to improve coverage for older Americans should consider trade-offs between defining eligibility by age versus ability to pay.

Objective: To learn whether consumer reports of health plan quality can affect health plan selection., Data Sources: A sample of 311 privately insured adults from Los Angeles County., Study Design: The design was a fractional factorial experiment. Consumers reviewed materials on four hypothetical health plans and selected one. The health plans varied as to cost, coverage, type of plan, ability to keep one's doctor, and quality, as measured by the Consumer Assessment of Health Plans Study (CAHPS) survey., Data Analysis: We used multinomial logistic regression to model each consumer's choice among health plans., Principal Findings: In the absence of CAHPS information, 86 percent of consumers preferred plans that covered more services, even though they cost more. When CAHPS information was provided, consumers shifted to less expensive plans covering fewer services if CAHPS ratings identified those plans as higher quality (59 percent of consumers preferred plans covering more services). Consumer choices were unaffected when CAHPS ratings identified the more expensive plans covering more services as higher quality (89 percent of consumers preferred plans covering more services)., Conclusions: This study establishes that, under certain realistic conditions, CAHPS ratings could affect consumer selection of health plans and ultimately contain costs. Other studies are needed to learn how to enhance exposure and use of CAHPS information in the real world as well as to identify other conditions in which CAHPS ratings could make a difference.

New government health insurance programs are likely to emphasize voluntary purchases in a market setting, with subsidies targeted at low-income populations and stress on managed care. Such programs are best structured with a guaranteed enrollment period that is as long as six months to a year. However, given that incomes change over time, errors will be made in awarding income-related subsidies for that long. These errors are assessed in simulations undertaken with longitudinal data from the Survey of Income and Program Participation. Two allocations of the subsidies, based on current income at the beginning of the enrollment period and on actual income assessed at the end, are compared for a variety of program designs. Prospective determination of subsidies is somewhat biased toward overpayment. Net overpayments amount to 5-10 percent of subsidy costs. However, prospective payment encourages participation in the subsidy program. The simulated participation rate for true eligibles is as high as 73 percent with prospective subsidies, compared to 69 percent with retrospective reconciliation. Net overpayments are slightly reduced by testing income less frequently and over longer periods.

Objectives: The Consumer Assessment of Health Plans Study (CAHPS) was developed to provide an integrated set of tested, standardized surveys to obtain meaningful information from health plan enrollees and their experiences. Many organizations began to implement CAHPS in 1997. Formal evaluations of the experiences of three demonstration sites with implementing CAHPS (ie, process evaluations) and the impact of CAHPS on consumer's choices (ie, outcome evaluations) were conducted. This article reports on the early findings and feedback from our process evaluations about the sites' experiences with using CAHPS. Results are presented from the first round demonstration sites, including the lessons learned during the demonstrations. Our plans for future demonstrations and evaluations are included., Methods: A similar evaluation design and instruments were used across demonstration sites. The process evaluation to monitor program intervention included on-site interviews, off-site review of documents, and focus groups with consumers., Results: There are 4 early results from the CAHPS demonstrations: (1) the CAHPS survey covers topics of importance to sponsors, is of reasonable length, and can be administered quickly; (2) the report templates are being used effectively, but sponsors vary widely in their preferences for summarizing and presenting CAHPS ratings; (3) standardized or off-the-shelf products are aspects of CAHPS that sponsors value highly, while emphasizing need for further development; and (4) because surveys like CAHPS require multiple within-plan samples to make plan comparisons, they require a substantial investment and may be affordable only for large sponsors., Conclusion: The first round CAHPS demonstrations highlighted the strengths of the integrated surveys and the areas for improving the products and the implementation process.

Objectives: The authors describe the process used to develop and test survey items targeted to Medicaid consumers for the Consumer Assessment of Health Plans Study (CAHPS). In addition, the authors highlight the special challenges in locating and surveying Medicaid recipients and provide recommendations for increasing response rates., Methods: The RAND CAHPS team reviewed the literature and existing questionnaires to identify health care issues and concepts important to Medicaid consumers. Three focus groups and 66 one-on-one cognitive interviews were conducted to test the relevance of our concepts and items and to identify additional concepts important to Medicaid consumers. After the cognitive interviews, the CAHPS Medicaid consumer survey was field tested using a sample of 930 adults and children receiving both Medicaid and Aid to Families with Dependent Children in Los Angeles County and Oklahoma. To determine if one particular mode were preferable for surveying a Medicaid population, our field test sample was divided randomly into a telephone-mode sample, a mixed-mode sample, and a second telephone-mode sample with enhanced locating procedures. Before finalizing the CAHPS 1.0 surveys, the full CAHPS item set was subjected to a formal literacy review., Results: The results of the focus groups and cognitive testing informed iterative versions of the list of concepts addressed by the Medicaid-targeted items. Concepts that were not relevant to Medicaid consumers or that consumers were unable to accurately attribute to a health plan were discarded. New concepts addressing important aspects of health care and the health care experience of Medicaid consumers were identified and added. Item wording and format were revised and refined based on the findings from focus groups, cognitive testing, the field test, and the formal literacy review. In the field test, the mixed-mode method achieved the best results with a 56% completion rate., Conclusions: The testing and formatting efforts described in this article, in combination with a formal literacy review, led to the development of a Medicaid questionnaire that measures the important health care experiences of Medicaid consumers in a format that is "respondent-friendly." Our recommendations for surveying Medicaid recipients can benefit any survey of a Medicaid population.

Objective: To investigate transitions in and out of Medicaid for a cohort of single adult women of childbearing age in order to address questions that arise as policymakers try to encourage transitions from welfare to work., Data Sources: Longitudinal data from Waves 2 through 8 of the 1990 panel of the Survey of Income and Program Participation, a nationally representative survey of American adults covering May 1990-1992., Study Design: We estimate a series of discrete-time logit models with duration dependence to obtain transition probabilities among Medicaid, privately insured, and uninsured spells. Explanatory variables in the models include prior insurance history, income limits on Medicaid by state, and important socioeconomic and demographic characteristics. We use these models to characterize insurance spells for a cohort of single women., Principal Findings: Most Medicaid spells are relatively short. Over half end in a year or less; only one spell out of seven lasts longer than five years. Two-thirds of Medicaid disenrollees become uninsured. Former welfare recipients are prone to frequent changes in insurance status. In states with more generous income limits for AFDC, women stay on Medicaid longer, but they do not move into the program at a faster rate., Conclusions: Imposing time limits on Medicaid eligibility would affect only a small proportion of Medicaid spells but would eliminate a significant proportion of the caseload at a point in time. In considering changes in Medicaid that would encourage transitions from welfare to work and would alter the dynamics of Medicaid, policymakers need to consider how transitions both in and out of private insurance and Medicaid would be affected.

This is a study of women's health insurance that makes both disaggregated and longitudinal comparisons between men and women to identify and describe gaps and sources of insecurity that are important for women. Income and family status are more important than gender in explaining health insurance differences. In many respects, the health insurance experiences of single women are more similar to those of single men than those of married women. Although married women often depend on their husbands for employer-sponsored insurance, the health insurance of married men and women is otherwise quite similar. Married women are at no greater risk of losing employer-sponsored insurance than married men, and married women experience fewer gaps and changes in coverage than single women (and single men). An expansion of coverage to all poor and uninsured adults would benefit more women than men by a small margin, despite the focus of Medicaid on low-income women. The married uninsured are concentrated just above the poverty line and have a big stake in whether public coverage programs extend above poverty. The main issue for women at higher income levels, especially for single women who cannot fall back on a spouse for coverage, is the danger of losing health insurance as a result of changes in employment.

Objectives: Universal coverage will trigger an increase in health-care spending, because the uninsured will use more services after they are insured. The effect of insurance status on expenditures is estimated here from a multivariate statistical model., Methods: The model is estimated with data from the 1987 National Medical Expenditure Survey, aged to 1994 using population projections from the US Bureau of the Census and expenditure projections from the Health Care Financing Administration., Results: Expenditures for the full-year uninsured increase by approximately $700 per person in 1994 as a result of universal coverage. Nearly half of the increase is because of a substantial increase in the likelihood of hospitalization., Conclusions: If the uninsured are enrolled in plans similar to those offered by employers currently, personal health-care spending increases by approximately $20 billion in 1994. There are other costs associated with universal coverage that are not included in this figure.

Data from three recent surveys indicate that about 40 percent of workers with employment-based health insurance are enrolled in plans that their employers self-insure. Despite the considerable differences between federal regulation of these self-insured plans and state regulation of employer plans purchased from an insurance company, we find striking similarities in the populations they serve, the benefits they offer, and their premium costs. Implications for health policy are discussed.

We estimate that at least 29 million Americans with private insurance are underinsured. That figure identifies the underinsured younger than 65 years by the risk of large out-of-pocket expenditures for an unusually expensive, catastrophic illness. A slightly smaller number, about 25 million, are underinsured by an alternate definition: they have insurance that pays a smaller proportion of claims than the plan with the largest enrollment in the federal employee program. The federal employee plan was the insurance standard proposed in several recent health system reform bills. Our estimate of the number of people who are underinsured for catastrophic illness is almost half again larger than the number that was widely cited during last year's debates on health system reform. That estimate was based on the same concept but was projected from a study published 10 years ago.

There are a number of proposals to expand substantially public financing of nursing home care. Included among the major elements of these proposals are front-end benefits limited to three or six months, back-end benefits with waiting periods of one or two years, and coverage of all nursing home days with or without substantial income-related cost sharing. Using data from the 1987 National Medical Expenditure Survey, this paper simulates the effect of these proposed changes in nursing home financing on public expenditures, Medicaid expenditures, and private expenditures (in total and by marital status and income group). The incentive for increased use of nursing home care also is examined. A short front-end benefit, the least expensive option in terms of public expenditures, increases public expenditures by $1 billion to $2 billion in 1987. Comprehensive coverage of all nursing home days increases public costs by $9 billion to $10 billion dollars, depending on the cost-sharing arrangement. There is wide variation in the range of plausible estimates because of uncertainty about the effect of increased public coverage of nursing home care on utilization.

Self-reported health status measures from the 1987 National Medical Expenditure Survey indicate significant differences among each of five population groups defined by current health insurance coverage. These differences in health status imply that the groups are likely to exhibit different patterns of expenditures, even if enrolled in the same health insurance after health care reform. The healthiest group along most dimensions is the population covered by employer-sponsored insurance, followed in order by the population with nongroup private insurance, the uninsured population, the population that qualifies for public coverage based on income, and the population that qualifies for public coverage based on medical need. While the general health and mental health of the uninsured are slightly worse in comparison to the privately insured, the uninsured have fewer chronic health problems. The uninsured who recently lost private insurance or who live in working families are significantly healthier than the long-term or low-income and nonworking uninsured.

Every year since 1984, Congress has expanded Medicaid to cover an increasing proportion of low-income children. In this study, a multivariate analysis of data from the 1987 National Medical Expenditure Survey was used to determine whether expanded Medicaid eligibility is likely to be effective in encouraging recommended preventive visits for low-income, preschool children. For low-income children who would otherwise be uninsured, a full year of Medicaid increased the probability of any well-child visits by 17 percentage points, and compliance with the guidelines of the American Academy of Pediatrics for well-child visits increased by 13 percentage points. The generosity of Medicaid fees did not alter the magnitude of these effects. However, even if all uninsured children under 200% of the poverty line were eligible for Medicaid, low-income children would continue to lag behind other children in their use of preventive services. Factors other than insurance and income, such as the lower educational attainment of low-income mothers, explain approximately 80% of the gap between children above and below 200% of poverty. The rate of compliance with the American Academy of Pediatrics guidelines was less than 50% for all preschool children. Departures from the recommended schedule of visits were particularly pronounced in the second year of life and may interfere with children receiving the recommended immunizations in a timely manner.

Estimates from the National Medical Expenditure Survey imply that in 1987 only two-thirds of elderly Medicare beneficiaries held the amount and type of insurance that is generally recommended to supplement Medicare, namely, 57.7% with private hospital/medical insurance from one source and 6.6% with only Medicaid. Of the remainder, 19.8% had more than one source of private insurance; slightly more than 1% had one source of extra-cash or disease-specific insurance as their only supplementary coverage; and 12.9% had no supplementary coverage at all. In addition, more than 500,000 Medicaid enrollees had purchased private insurance, despite the comprehensive coverage offered by Medicaid. Although the issue of multiple coverage has been dramatized by stories of poor, very elderly persons who have purchased numerous Medigap plans, beneficiaries who purchase coverage from more than one source are likely to be relatively young, more highly educated, and financially better off.

Data from a nationally representative sample of nursing-home residents at the beginning of 1987 are used to assess the interaction of Medicaid asset spend-down, the distribution of nursing-home days by payment source, and the effect of proposed changes in public financing of nursing-home care. Three out of five nursing-home residents were covered by Medicaid in January 1987; nearly all of the remainder were private-pay. Most Medicaid recipients were covered by Medicaid when they entered the care facility at the start of an episode, but 18 percent had spent down and were originally admitted as private-pay. A universal nursing-home benefit that insured the first six months of each nursing-home episode would cover 16 percent of the people in nursing homes on a given day, disproportionately those who are private-pay. A universal benefit with a 24-month waiting period would cover 56 percent of nursing-home residents on a given day, and would tend to favor those financed by Medicaid.

In the Institutional Population Component of the 1987 National Medical Expenditure Survey, the definition of a nursing home admission was standardized to ignore the readmission of patients discharged for short-term hospital care. Approximately one out of six persons residing in nursing homes on the survey reference date (January 1, 1987) had been readmitted for this reason. The effect of the standardization was to increase the average length of stay of residents prior to the reference date by approximately 5 months. The percentage of long-stay residents, those living in the facility for more than three years, increased from 31% to 36%. The percentage admitted from the community during the previous year increased from 32% of those admitted in 1986 to 41%.