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The Rural Uninsured: Highlights from Recent Research

By Thomas D. Rowley

The author is an independent researcher, writer, and editor based in Arlington, Virginia.
This study was funded under a cooperative agreement with the Federal Office of Rural Health Policy, Health Resources and Services Administration, DHHS (# U1CRH00025).

The latest numbers show an increase of 2.5 million in the number of Americans without health insurance, some 14.6 percent (41.2 million) were without coverage during the entire year in 2001. (September 2002, Current Population Survey) Consequently, the lack of insurance-or uninsurance--remains an issue of great concern to the general public, policymakers, and researchers. Of particular interest to parties focused on rural issues are the rural dimensions of uninsurance: how it differs from urban uninsurance, how it differs across rural America, and how it affects rural healthcare providers. This report highlights findings from 11 recent studies on rural uninsurance to help answer such questions.


Importance of Insurance

Individuals know well the importance of health insurance: without it, health care is often simply unaffordable. Health insurance status-whether one has it or not-can mean the difference in getting medical care and going without.

The health insurance status of the U.S. population, especially the size and composition of the uninsured, concerns the general public and policymakers for several reasons.

  • Since health insurance is critical in ensuring that people get timely access to medical care, it is critical to the health and well-being of the population.
  • The health insurance status of the population has great bearing on several equity and efficiency dimensions-the appropriate amount of public subsidization of health care, the impact of insurance on the efficient use of care, and the way in which insurance affects the distribution of care across the population.
  • Timely and accurate estimates of the population's health insurance status are essential in crafting and evaluating public policies aimed at expanding insurance coverage. (Rhoades et al.)

The Rural Difference

Whether urban or rural, the uninsured are predominantly low-income, working Americans and their families, and most have no insurance because they do not obtain coverage from their workplace-either because it is not offered or it is not affordable. (Rowland).

Despite these similarities, significant differences exist between the rural and urban uninsured. One difference that remains a bit unclear, however, is that of the rural rate of uninsurance versus the urban rate. Which exceeds the other and by how much depends upon the type, time, and design of the surveys yielding those estimates-each having its own set of strengths and weaknesses. (Fronstin)

Using the March 1999 Current Population Survey (which measured health insurance status in 1998), Pol found that the urban rate was higher than the rural (16.4 percent vs. 15.7 percent). Using 1998 case study data and looking at states rather than the nation, Ormond, Wallin, and Goldenson found that the rural rate exceeded the urban in all five of their study states. The 2001 Current Population Survey (the most recent data available for rural areas) shows that nationally, the urban rate is still higher than the rural (14.2 percent vs. 13.1 percent).

Regardless of the exact number of rural uninsured and whether it exceeds the urban number, other important differences between the rural and urban uninsured on several dimensions appear to be clearer and more consistent.

Differences in type of coverage. Ormond, Zuckerman, and Lhila found that the proportion of the non-elderly population covered by private health insurance (primarily employer-sponsored coverage) falls as the county of residence gets more remote, dropping from 74.6 percent for urban residents to 71.5 percent for residents of rural counties next to an urban county (rural adjacent)) to 62.6 percent for residents of rural counties removed from any urban county (rural nonadjacent).

And while public coverage helps meet some of the need in rural areas created by a lack of private coverage (15.5 percent of rural, nonadjacent residents were publicly insured, compared with only 11.1 percent of urban residents), the percentage of people left without any health insurance--public or private--increases as the county of residence gets more remote: from 14.3 percent in urban to 17.5 percent in rural adjacent to 21.9 percent in nonadjacent areas.

Differences in employment. According to Pol, disproportionately more rural residents than urban rely on individual insurance plans or insurance coverage purchased through small employers. And among rural residents who are employed, a higher proportion than the urban employed is in a job not conducive to moderately priced group health insurance-that is working for a small employer, self-employed, or in an agricultural occupation. Ormond, Wallin, and Goldenson support this assertion with their finding that lower rural coverage rates are associated with the prevalence of part-time or self-employment in the rural economy.

Differences in length of time without insurance. In a study of Nebraska households, Mueller, Patil, and Ullrich found that the median spells of uninsurance were approximately six months for urban residents, 16 months for rural residents, and 22 months for frontier residents. In addition, they found that spells were more likely to end for urban residents regardless of the length of the spell.

Looking at physician utilization following a spell of uninsurance (that is, once residents gained insurance), the researchers found that urban residents actually decreased their utilization, frontier residents increased theirs, and rural residents maintained their existing pattern. Possible reasons for the decrease in urban utilization, according to the study, include 1) urban residents had not interrupted their normal pattern of utilization during the spells of uninsurance because the spells were relatively short, 2) urban residents had increased their visits to physicians near the end of the spell because of the availability of free care at clinics and the prospect of paying co-payments and/or deductibles once insurance was obtained, and 3) urban residents were faced with pre-existing condition clauses in their newly gained insurance coverage, which kept them away from the doctor.

Possible reasons for the increased utilization among frontier residents include 1) frontier residents had a pent-up demand for care because of their longer spells of uninsurance, 2) frontier residents may have been less likely while uninsured to seek free care out of a sense of pride as well as a lack of access to free clinics, and 3) frontier residents did not let expectations of co-payments or deductibles deter them from seeking care once insurance was obtained.

Differences among population groups. Select groups within the overall population-particularly those who are vulnerable in terms of economic and/or health concerns--are often of special interest to policymakers. In a study focused on rural minorities, Mueller, Patil, and Boilesen found that lack of insurance, rural residence, and minority status all combine to lower the utilization of healthcare services.

In a study focused on rural children, Coburn, McBride, and Ziller found that rural children were more likely than urban to lack health insurance at a point in time. Rural children were also more likely to have protracted spells, but the average duration of uninsurance was shorter for rural children. Looking at the characteristics of the uninsured children, the researchers found that a higher proportion of rural children lived in poverty-a fact that likely contributed to their lack of insurance.

Differences in need. Difference in health insurance status between rural and urban people takes on additional importance when one considers that rural populations tend on average to be older, poorer, and have lower levels of education-all of which can contribute to a lower health status and a higher need for health care. (Ormond, Zuckerman, and Lhila)

Differences among rural areas. Rural America is diverse. Its economies, terrains, cultures, assets, and liabilities vary. Issues related to health insurance vary as well, as shown in differences between rural areas that are adjacent to urban areas and rural areas that are not, and between different subgroups of the rural population. Consequently, the rural uninsured cannot be thought of as a single, homogenous group.


Impacts on Rural Health Care Providers

Not surprisingly, health insurance (and the lack thereof) has great impact on health care providers and, by extension, on the availability of health care in a given area. To a large extent, health insurance status of patients determines whether and how much health care providers are paid for their services. And while most health care providers expect to provide a certain amount of uncompensated care, such care can, if it becomes too large a share of a provider's services, endanger a provider's ability to continue service.

In looking at the rural health care safety net, Ormond, Walling, and Goldenson report that because rural areas have a higher proportion of Medicare and Medicaid enrollees as well as a higher proportion of uninsured (according to their findings) than do urban areas, providers in rural areas are potentially more vulnerable-subject to state and federally determined reimbursement rates on the one hand and asked to provide more charity care on the other.

Sutton et al. provide a measure of that vulnerability. In their study of uncompensated and charity care by rural hospitals, they found that approximately 17 percent of the 246 rural counties studied were at risk of losing access to local hospital services because all hospitals in the counties had an average 3-year negative total margin of profit. They also found that rural hospitals that treat a high proportion of low-income patients provide significantly more charity and uncompensated care than do other hospitals.


For Further Analysis…

As with many domestic policy issues, efforts to help the uninsured are crafted and delivered at various levels-federal, state, and local. As a result, there is a need for research and analysis, and therefore data collection, at all levels. Socholitzky and Turnbull provide a guide to help local groups obtain data on the uninsured people in their communities.

Given the importance of health insurance coverage in affecting access to health care and subsequent health status, it is essential to continue monitoring the extent to which the rural population is receiving such coverage.


The Reports

The reports included in this summary were selected because 1) they focused on one or more aspects of health insurance coverage (or lack thereof) in rural areas, and 2) they were prepared within the last five years. The reports come from a range of institutions, including the federally funded Rural Health Research Centers. They were identified by the federal Office of Rural Health Policy and through a literature search provided by the Rural Information Center Health Service.

Following, is the list of reports in order of appearance in the above synthesis.

"Health Insurance Status of the Civilian Noninstitutionalized Population: 1998", by J. Rhoades, E. Brown, and J. Vistnes. MEPS Research Findings No. 11. Agency for Healthcare Research and Quality. April 2000.

"Low-Income and Uninsured: The Challenge for Extending Coverage," by D. Rowland. The Kaiser Commission on Medicaid and the Uninsured. Testimony before the U.S. Senate Committee on Finance. March 13, 2001.

"Counting the Uninsured: A Comparison of National Surveys," by P. Fronstin. EBRI Issue Brief Number 225. Employee Benefit Research Institute. September 2000.

"Supporting the Rural Health Care Safety Net," by B. Ormond, S. Wallin, and S. Goldenson. Occasional Paper Number 36. Assessing the New Federalism. The Urban Institute. March 2000.

"Rural/Urban Differences in Health Care Are Not Uniform Across States," by B. Ormond, S. Zuckerman, and A. Lhila. Assessing the New Federalism. Series B, No. B-11. The Urban Institute. May 2000.

"Health Insurance in Rural America" by L. Pol. Rural Policy Brief 5(11). RUPRI Center for Rural Health Policy Analysis. August 2000.

"Lengthening Spells of Uninsurance and Their Consequences," by K. Mueller, K. Patil, and F. Ullrich. J of Rural Health, Vol. 13, No.1. Winter 1997.

"The Role of Uninsurance and Race in Healthcare Utilization by Rural Minorities," by K. Mueller, K. Patil, and E. Boilesen. HSR: Health Services Research, Vol. 33. No. 3. August 1998.

"Patterns of Health Insurance Coverage Among Rural and Urban Children" by A. Coburn, T. McBride, and E. Ziller. Working Paper #26. Maine Rural Health Research Center. November 2001.

"Is the Rural Safety Net at Risk? Analyses of Charity and Uncompensated Care Provided by Rural Hospitals in Washington, West Virginia, Texas, Iowa, and Vermont" by J. Sutton, B. Blanchfield, A. Singer, and M. Milet. Project HOPE Walsh Center for Rural Health Analysis. January 29, 2001.

How Many Uninsured? A Resource Guide for Community Estimates, by E. Socholitzky and N. Turnbull. The Access Project. June 1999.


"Health Insurance Status of the Civilian Noninstitutionalized Population: 1998", by J. Rhoades, E. Brown, and J. Vistnes. MEPS Research Findings No. 11. Agency for Healthcare Research and Quality. April 2000.

The health insurance status of the U.S. population is strongly associated with specific demographic characteristics, health status, and employment status. Significant disparities in coverage exist for particular groups.


OBJECTIVE

To provide preliminary estimates of the number and characteristics of people with private and public health insurance at any time during the first half of 1998, on average. Particular emphasis is given toward estimating the size of the population that was uninsured throughout the first half of 1998 and identifying groups especially at risk of lacking health insurance.


DATA

Source: 1998 Medical Expenditure Panel Survey (MEPS). Agency for Healthcare Research and Quality and the National Center for Health Statistics.

Description: Provides nationally representative estimates of health care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. Also includes a nationally representative sample of nursing homes and their residents.


BACKGROUND

The health insurance status of the U.S. population, especially the size and composition of the uninsured, is an issue of public policy concern for several reasons:

  1. Insurance is essential to ensure that individuals obtain timely access to medical care and protection against the rise of expensive and unanticipated medical events. Insured people are more likely to have a usual source of medical care, spend less out of pocket on health services, and experience different treatment patterns, quality, and continuity in their health care.
  2. Concern over the population's health insurance status reflects a variety of equity and efficiency considerations, including the magnitude and appropriate mix of private and public sector responsibility for financing care, the impact of insurance on the efficient use of care, and the manner in which insurance affects the distribution of care among the general population and across groups of specific policy interest.
  3. Timely and reliable estimates of the population's health insurance status are essential in evaluating the costs and expected impact of public policy interventions to expand coverage or alter the way in which private and public insurance is financed.
  4. Comparisons of the characteristics of the insured and uninsured over time tell us whether greater equity has been achieved in the ability of specific population groups to obtain insurance or whether serious gaps remain.


KEY FINDINGS

Overall

  • During the first half of 1998, on average, 84.2 percent of all Americans in the civilian noninstitutionalized population had some type of private or public health insurance. Nearly 69 percent of Americans obtained health insurance from private sources. Another 15.6 percent obtained public sources of coverage, primarily from Medicare and Medicaid. The remaining 15.8 percent (42.3 million) were without health insurance.

Residential Location

  • People living in the South and West were less likely than residents of other regions to have private health insurance (64.8 percent and 65 percent in the South and West, respectively, compared to 70.8 percent and 76.1 percent of residents in the Northeast and Midwest). Nearly one out of five persons in the South and West were uninsured (18.8 percent and 18.1 percent, respectively), compared to 12.7 percent in the Northeast and 11.4 percent in the Midwest.
  • People living in rural areas (outside MSAs) were less likely than those living in urban areas (within MSAs) to be covered by private health insurance (64 percent versus 69.8 percent).

Age

  • Among the non-elderly population, 70.4 percent were covered by private insurance, 11.8 percent were covered by public insurance, and 17.8 percent (42 million) were uninsured.
  • Over half of elderly Americans (55.3 percent) were covered by private insurance; 43.8 percent held only public coverage. These estimates differ significantly from estimates for 1997, when 60.5 percent of the elderly were covered by private insurance and 38.4 percent were covered by public health insurance only. Presently there are insufficient data to determine why these changes have occurred between the two years.
  • Nearly one-third (31.8 percent) of young adults aged 19-24 were uninsured, twice the rate for the population in general. They also had the lowest rate of private coverage among the non-elderly adult population.
  • Children are more likely than non-elderly adults to have health insurance. From 20-30 percent of children 12 and under with insurance were covered by public insurance. Nevertheless, 10.6 million children lacked coverage.

Employment Status

  • Since most private health insurance is provided through employers, employment status is an important indicator of access to private coverage. According to the survey, 79.9 percent of workers were covered by private insurance, compared to 51.2 percent of people who were not employed.
  • Those who were not employed were more likely than workers to be covered by public insurance (23.1 versus 3.4 percent). And workers were less likely than those not employed to be uninsured (16.6 percent versus 25.6 percent).

Race/Ethnicity

  • White Americans were more likely than either Black or Hispanic Americans to be insured and, if insured, to have private insurance. The rates of coverage: White (87.8 percent), Black (79.4 percent), Hispanic (68.2 percent). The rates of private coverage: White (75.7 percent), Black (50.2 percent), Hispanic (46.9 percent).
  • Among all racial/ethnic groups, Hispanic males were the most likely to be uninsured (33.9 percent).

Marital Status

  • Married individuals were more likely than non-married to have private insurance. Indeed, among people ages 16-64, married individuals were more likely to have private coverage (81.8 percent) and less likely to have public coverage (4.5 percent) or be uninsured (13.7 percent).

Health Status

  • More than one in five non-elderly Americans in good health (20.8 percent), fair health (23.2 percent), or poor health (22.8 percent) were uninsured throughout the first half of 1998.
  • People in fair or poor health were less likely than those in better health to have private health insurance. Only 41.2 percent of those in poor health and 53.8 percent of those in fair health had any private coverage.
  • Public insurance helped to reduce the health-related disparities in private coverage. Over 20 percent of people in fair health and over one-third of people in poor health had public coverage. Nevertheless, those in only good or fair health were more likely than people in very good or excellent health to be uninsured.
  • Elderly Americans in poor health were less likely than those in good or better health to have private coverage and more likely to be covered by public insurance only (55.9 percent).

Characteristics of the Non-Elderly Uninsured

  • Children under age 18 comprised 25.2 percent of the uninsured population under age 65.
  • Young adults ages 19-24 made up 8.8 percent of the non-elderly population but accounted for 15.7 percent of the uninsured non-elderly population.
  • Males made up slightly less than half of the non-elderly population but accounted for 54 percent of the uninsured non-elderly population.
  • Hispanics represented only 12.3 percent of the non-elderly population but 23.1 percent of the uninsured non-elderly population.
  • Whites accounted for 70 percent of the non-elderly population but less than 60 percent of the uninsured non-elderly.
  • Southerners represented 35 percent of all non-elderly Americans but 42 percent of the uninsured non-elderly.
  • People who never married accounted for more than a fifth of the non-elderly population but more than a third of the non-elderly uninsured.


IMPLICATIONS

  • Public health insurance will continue to play an important role in insuring children, Black Americans, and Hispanic Americans.
  • To be most effective, public policies to provide and promote health insurance will need to take into account the differences among various groups.


"Low-Income and Uninsured: The Challenge for Extending Coverage," by D. Rowland. The Kaiser Commission on Medicaid and the Uninsured. Testimony before the U.S. Senate Committee on Finance. March 13, 2001.


The uninsured population is predominantly low-income, working Americans and their families. Efforts to extend coverage to them must address the high cost of coverage and the lack of access to private health insurance for low-wage workers.


OBJECTIVE

To provide a profile of the low-income uninsured population and discuss factors contributing to their lack of insurance and the importance of broadening coverage.


DATA

Sources: Various


BACKGROUND

Most Americans receive their health insurance through an employer-sponsored health plan offered through the workplace, but for millions of working families, such coverage is either not offered or is not affordable. Medicaid and State Children's Health Insurance Program (CHIP) help fill the gaps for some of the lowest income people, but that coverage is directed primarily to children and varies across states. As a result, in 1999, 42 million Americans were without health insurance.


KEY FINDINGS

  • The uninsured are predominantly low-income working families-two-thirds (65 percent) of uninsured families have incomes below 200 percent of the poverty level.
  • Most of the uninsured have no insurance because they do not obtain coverage in the workplace. Eight in ten of the uninsured come from working families, but over 70 percent of all uninsured workers do not have access to job-based coverage. Low-wage workers are particularly disadvantaged-only 55 percent of low-wage workers earning $7 per hour or less are offered coverage, compared to 96 percent of workers earning more than $15 per hour.
  • Although most workers participate in employer health plans when offered, affordability is a major issue. On average, employees contribute 26 percent of premium costs ($1,656 in 2000). For a full-time worker earning $7 per hour, the employee share of premiums represents over 10 percent of the family's annual $14,500 income.
  • Medicaid assists many low-income families by providing health insurance with limited cost sharing and essential benefits to 21 million low-income children and 8 million parents. However, millions of low-income adults remain ineligible for coverage under Medicaid and many people who are eligible, especially children, are not enrolled.
  • Lack of health insurance influences when and whether the uninsured get necessary medical care, the financial burdens they face in obtaining care, and, ultimately, their health.


IMPLICATIONS

  • Extending coverage to the millions of Americans without health insurance is both an important policy and health objective.
  • Any effort to extend coverage to the low-income uninsured must address the high cost of coverage and the lack of access to private health insurance.
  • The most immediate and potentially most effective means of broadening coverage is to build on the current public programs-Medicaid and CHIP-that have been designed to provide health coverage for low-income populations.


"Counting the Uninsured: A Comparison of National Surveys," by P. Fronstin. EBRI Issue Brief Number 225. Employee Benefit Research Institute. September 2000.

Copyright 2000 by the Employee Benefit Research Institute. Material excerpted with permission.


Estimates of the number of uninsured vary depending on the type, time, and design of the surveys yielding those estimates.


OBJECTIVE

To review surveys that provide estimates of the uninsured population in the United States and discuss why the estimates vary.


DATA

Sources:

Current Population Survey (CPS), U.S. Census Bureau.
Survey of Income and Program Participation (SIPP), U.S. Census Bureau.
Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control.
Community Tracking Study (CTS), Center for Studying Health System Change.
Medical Expenditure Panel Survey (MEPS), Agency for Healthcare Research and Quality.
National Health Interview Survey (NHIS), National Center for Health Statistics.
National Survey of America's Families (NSAF), The Urban Institute.

Descriptions: See "Key Findings"


BACKGROUND

Seven different surveys can be used to make nationally representative estimates of the number of people without health insurance. Not surprisingly, the estimates vary from survey to survey. As of September 2000, the estimates ranged from 19 million to 44 million.

Understanding the differences in the estimates is critical for two reasons. First, the projected cost of implementing policy proposals depends on the estimates of the number of people affected by the proposals. Second, the estimated effectiveness of policy proposals to reduce the number of uninsured will be accurate only if the correct count is known and the precise make-up of the uninsured population is understood.

SEE TABLE

Current Population Survey (CPS)

Conducted monthly, the CPS interviews approximately 50,000 households, representing more than 130,000 individuals. It is the primary source of data on labor force characteristics of the U.S. civilian noninstitutionalized population and the official source of data on unemployment rates, poverty, and income.

Households are scientifically selected on the basis of geographic region of residence to collect data representative of the nation, individual states, and other specified areas.

Since 1980, the supplement to the March CPS has included questions on health insurance coverage. Separate questions are asked about employment-based health insurance, health insurance purchased directly from an insurer, insurance from a source outside of the household, federal insurance programs, or other state-specific health programs fro low-income uninsured individuals. The questions on health insurance refer to the entire previous calendar year. No question about being uninsured is asked. Estimates of the uninsured are calculated as a residual.

Pros and Cons:

  • Individuals potentially are asked to recall the type of health insurance they had 14 months prior to the interview.
  • Some individuals do not understand the question and report the type of health insurance they have as of the interview date.
  • CPS may not be picking up all Medicaid recipients because some states do not call the program Medicaid. CPS tries to compensate for this by referring to the Medicaid program by its state-specific name during the interview.
  • CPS has undergone a number of changes over the years that affect the comparability of the data in the time series.

Survey of Income and Program Participation (SIPP)

The SIPP collects data on income sources and amounts, labor force participation, program eligibility and participation, and general demographic characteristics in order to measure the effectiveness of existing federal, state, and local programs; to estimate future costs and coverage for government programs; and to provide improved statistics on income distribution in the United States.

It is a longitudinal survey based on a continuous series of national panels, with sample size ranging from approximately 14,000 to 36,700 interviewed households. Households are followed between two and one-half years to four years in each panel. The sample is a multi-stage-stratified sample of the U.S. civilian noninstitutionalized population.
SIPP tracks individuals' health insurance coverage on a monthly basis. Specifically, respondents are asked about health insurance coverage during the four months prior to the interview. It asks detailed questions about health insurance. Estimates of the uninsured are calculated as a residual.

Pros and Cons:
  • According to Census Bureau officials, SIPP may be better suited than the CPS to measure insurance coverage and the uninsured. First, it may have less recall error than CPS, since SIPP respondents have a short recall period-4 months compared with 14. Second, SIPP questions are more detailed than CPS questions. Third, SIPP attempts to interview each person in the household age 15 and older while CPS interviews only one person, who may not provide accurate information about other household members.
  • Because SIPP tracks the same individuals over time, the survey suffers from sample attrition and, as a result, possible sample bias. In general, attrition tends to be more common for minorities, lower-income groups, and the uninsured.
  • The four-month window can be a weakness, because respondents typically respond with the same answer for each month about which they are being interviewed. For example, persons interviewed in July would often offer the same answers for their insurance status in February, March, April, and May, even if their status had changed during those four months.

Behavioral Risk Factor Surveillance System (BRFSS)

The BRFSS gathers data on health risk behaviors at the state level in order to promote healthy personal behaviors. Data are used to educate the public, to improve public health strategies, and to identify variations in health risk behaviors and in emerging and critical health issues.

Data are collected monthly via telephone surveys conducted by state health departments. States make calls for about two weeks out of every month, completing between 125 and 625 interviews per month, for an annual total of more than 150,000 interviews.

Households are selected using a random sampling of telephone numbers, and one adult per selected household is interviewed.

Health insurance coverage rates are estimated using a group of questions on health care access, which have varied over time. Health insurance status was first queried in 1991. Since 1993, a follow-up question has been asked of respondents who answered "no" when asked if they had insurance, in order to get information on how long they have been without coverage.

Pros and Cons:

  • The survey collects information only on the adult who answers the telephone, and it does not include information on children.
  • Only one adult per household is interviewed, and that person may not be representative of the other adults or children in the household. This may result in underestimating the number of uninsured.
  • Only households with telephones are included in the survey, which may also underestimate uninsurance rates.
  • Yearly changes to the survey may affect the comparability of the results from year to year.
  • The length of time that a person is uninsured is subject to significant recall bias and may be misreported.

Community Tracking Study

The CTS is a nationally representative household survey designed to obtain information on access to healthcare, use of care, financial burden, satisfaction with care, and health insurance coverage. The survey has been conducted in 1996-97 and again during 1998-99. It is expected to be repeated on a two-year cycle.

The CTS is primarily a telephone survey of 33,000 households in the contiguous 48 states. It was supplemented with a sample of large metropolitan area households that do not have telephones. Information was collected on all adults in the household and for one randomly selected child in each household.

Detailed questions were asked about employment-based health insurance, insurance purchased directly from an insurance company, insurance from outside the household, and public sources of health insurance. Unlike other surveys, CTS did not estimate uninsured numbers as a residual. Rather, it asked individuals who reported no type of insurance to verify the fact that they were uninsured. This helps explain why the CTS reports fewer uninsured than CPS or MEPS.

Pros and Cons:

  • While the CTS is nationally representative, it cannot be used to estimate the number of uninsured by state.

Medical Expenditure Panel Survey (MEPS)

MEPS was first conducted in 1996. Panel 1 of the survey was conducted in 1996-97. Panel 2 covers 1997-98. More than 10,000 households were sampled, representing more than 20,000 individuals.

Respondents are interviewed six times over the course of two and one-half years, resulting in two complete calendar years of data for each household. Like SIPP, MEPS collects data on a monthly basis through a combination of computer-assisted in-person interviews and telephone interviews. The sampling frame is drawn from the National Health Interview Survey (described below).

The survey asks detailed questions about Medicare, Medicaid, Tricare, employment-based coverage, union coverage, former employer coverage, coverage from outside the household, and coverage purchased in the individual market. It does not ask about being uninsured; uninsured data are calculated as a residual.

Health insurance information is collected for a specific time period, known as the "reference period." The reference period for the first round of the 1996 survey went from January 1, 1996 to the date the person was interviewed-sometime from March to June. Therefore, the uninsured estimate should reflect the number of persons who were uninsured, on average, during the first six months of 1996.

Pros and Cons:

  • For confidentiality reasons, state identifiers are not included in the public-use file, although they can be accessed at a data center. The data are not representative of the states.

National Health Interview Survey (NHIS)

The NHIS, conducted annually, is the principal source of information on the health of the civilian noninstitutionalized population of the United States. Data are used by the U.S. Department of Health and Human Services to monitor trends in illness and disability and to track progress toward achieving national health objectives. The data are also used by the public health research community for epidemiological and policy analysis.

The NHIS is a cross-sectional household interview survey that is nationally representative of the civilian noninstitutionalized population, with over sampling of blacks and Hispanics. Sampling and interviewing are continuous throughout each year. Approximately 43,000 households, including about 106,000 individuals, are surveyed.

The survey asks who in the household is covered by health insurance and by what kind of coverage. Prior to 1997, the uninsured was calculated as a residual. Beginning in 1997, however, a question was added to verify that persons not reporting health insurance coverage were in fact uninsured.


Pros and Cons:

  • Representative estimates cannot be drawn from all states due to small sample sizes.
  • State-level can accessed only from the National Center Health Statistics Research Center.
  • NHIS has not been used often to make estimates of the uninsured because there is a long lag time between the collection and release of data.

National Survey of America's Families (NSAF)

The NSAF was designed to examine employment, earnings and income, education, job training, economic hardship, family structure, housing arrangements and cost, health insurance coverage, access to and use of health services, health status, and other areas.

First conducted in 1997, more than 44,000 households were interviewed, including 110,000 individuals under age 65. The survey was conducted over the telephone; a sample of households without phones was also included.

Like the CTS and BRFSS, the NASF has added a question to verify whether individuals were in fact uninsured.

Pros and Cons:

  • While the survey is nationally representative of the noninstitutionalized population under age 65, state estimates can be derived for only 13 states: Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin.


IMPLICATIONS

  • While the CPS is widely used to examine the uninsured, and is the most well known survey on health insurance coverage, it is not without weaknesses. As a result, other surveys have begun to collect data on health insurance coverage and the uninsured.
  • Each of these surveys, however, also has weaknesses. Some are not designed to measure the levels of the uninsured. Others, because they are short and conducted over the telephone, may not obtain accurate information about health insurance coverage and/or may undercount vulnerable populations.
  • Research is needed to increase the understanding of the differences among the surveys and to improve on methodologies to count the uninsured.

"Supporting the Rural Health Care Safety Net," by B. Ormond, S. Wallin, and S. Goldenson. Occasional Paper Number 36. Assessing the New Federalism. The Urban Institute. March 2000.

Copyright 2000 by The Urban Institute. Material excerpted with permission.

The consequences of losing a provider are potentially greater in rural areas than in urban. Furthermore, it is the elderly and uninsured poor who will suffer most.


OBJECTIVE

To discuss the challenges faced in the health care sector in several communities and describe the ways in which governments and individual providers in these communities have attempted to strengthen rural health delivery systems and ensure access to essential health services, particularly for the low-income population.

Insurance coverage is only a small part of the report.


DATA

Source: 1998 case studies, The Urban Institute.

Description: Case studies of 11 rural communities across five states-Alabama, Minnesota, Mississippi, Texas, and Washington--were part of the Institute's Assessing the New Federalism. States were selected to represent a broad range of pressures facing rural providers and to show the variety of government and provider responses to these pressures. Site visits were conducted May to September 1998. Authors interviewed hospital and clinic administrators, physicians, health department directors, county social services directors, and county commissioners.


BACKGROUND

Changes in the health care sector are threatening many providers, both rural and urban. The consequences of the failure of a provider, however, whether it be a health facility or a health professional's practice, are potentially greater in rural areas. Because alternative sources of care in the community or within a reasonable proximity are scarce, each provider likely plays a critical part in maintaining access to health care in the community. For this reason, in most rural communities all providers should be considered part of the health care safety net-if not directly through their care for vulnerable populations, then indirectly through their contribution to the stability of the community's health care infrastructure.


KEY FINDINGS

  • In general, rural residents are less likely to have health insurance coverage than are urban residents. Though rates vary across the study states, rural uninsurance rates exceed urban rates in all study states.
  • Lower rural coverage rates are associated with higher poverty in rural areas but also with the prevalence of part-time employment or self-employment in the rural economy. Nationally, employer-sponsored coverage is lower in rural areas than in urban areas. In areas of high self-employment, insurance coverage rates may obscure the problem of the adequacy of coverage. Respondents in several counties reported that many self-employed people purchase policies with a high deductible, which makes coverage more affordable but may leave families with inadequate coverage for routine care.
  • Higher rural poverty rates mean that rural residents, if insured, are more likely to be covered by public programs-e.g., Medicaid-than are urban residents.
  • Restrictions on Medicaid benefits vary across the study states. In Alabama and Mississippi, there are limits on the number of inpatient days, physician office visits, and non-emergency outpatient status.
  • The states vary in dealing with poor and uninsured residents who are not eligible for Medicaid. Minnesota and Washington have state programs that help residents get subsidized insurance. In Texas, counties are legally responsible for indigent care. In Mississippi and Alabama, there are no public programs beyond Medicaid to extend health insurance to the uninsured.
  • Within the insured population, both public and private, the prevalence of managed care is low in rural areas compared with urban. In 1995, 1 percent of the rural population and 25 percent of the urban were enrolled in HMOs.
  • For Medicaid recipients, participation in managed care is increasingly becoming mandatory, though less often for rural beneficiaries than for their urban counterparts.
  • The uncompensated care burdens of the hospitals in the study counties were generally under 10 percent but ranged from insignificant to nearly 25 percent of revenues. Respondents credit the expansion of Medicaid in the early 1990s with a lower demand for charity care, and all say that no one is refused care for lack of ability to pay.
  • Underinsurance is a more important source of uncompensated care for rural hospitals than is likely the case for most urban facilities.
  • The major provider of ambulatory care to the uninsured varied by community, but private-practice physicians were more likely to treat insured patients, and uninsured patients were usually seen at either the emergency room or the local community or rural health clinic.

IMPLICATIONS

  • In rural areas where Medicaid covers a higher proportion of the population, limitations on services for Medicaid recipients could potentially increase the demand for uncompensated care and exacerbate the financial difficulties of local providers.
  • Given the higher proportion of Medicare and Medicaid enrollees and uninsured in rural areas, physicians in rural areas may find themselves subject to state or federally determined reimbursement schedules on the one hand and asked to provide more charity care on the other.
  • If a hospital is unable to maintain the services necessary to be a provider of first resort rather than last, more affluent, insured residents may bypass the local hospital, leaving it to serve primarily uninsured or publicly insured residents and threatening its financial security.
  • Closure of rural health care facilities would be most serious for the elderly and uninsured poor, because younger and higher-income residents are better able to travel outside the community to get care.

"Rural/Urban Differences in Health Care Are Not Uniform Across States," by B. Ormond, S. Zuckerman, and A. Lhila. Assessing the New Federalism. Series B, No. B-11. The Urban Institute. May 2000.

Copyright 2000 by The Urban Institute. Material excerpted with permission.

Fundamental differences exist between urban, rural, and remote areas in terms of health insurance coverage, access to care, health care utilization, and confidence in getting care.


OBJECTIVE

To present data on insurance coverage, health status, health care visits, and confidence in getting care for persons under age 65 across urban areas, rural areas adjacent to urban areas, and rural areas not adjacent to urban.


DATA

Source: 1997 National Survey of America's Families (NSAF), The Urban Institute.

Description: A survey of children and adults under the age of 65 in more than 44,000 households. The survey provides representative information for the 13 focal states that are part of the Institute's study, Assessing the New Federalism, and for the nation as a whole. It contains data on insurance coverage, health status, access to care, and use of health services.

Of the 13 states, only eight-Alabama, Colorado, Michigan, Minnesota, Mississippi, Texas, Washington, and Wisconsin-have substantial rural populations and are included in this report. Among those eight, the rural population ranges from a high of 69.5 percent in Mississippi to a low of 15.5 percent in Texas.

Counties are classified according to the USDA rural-urban continuum code. Urban residents live in metropolitan counties. Rural, adjacent residents live in nonmetropolitan counties adjacent to a metropolitan county. Rural, nonadjacent residents live in nonmetropolitan counties not adjacent to a metropolitan county.


BACKGROUND

Rural residents may have greater health care needs and face greater barriers to obtaining service than urban residents. Rural populations are generally older, poorer, and have lower levels of education than their urban counterparts. In addition, there are fewer hospitals and physicians in rural areas; the time it takes to travel to health care providers is often greater and public transportation is less available. These problems may be magnified in rural areas distant from any urban center.

As the federal government gives states greater responsibility for designing health policies, the fundamental differences between rural and urban areas as well as among different types of rural areas will need to be recognized.


KEY FINDINGS

  • Income is correlated with many health status and access characteristics. Rural areas tend to be poorer than urban areas, and the more isolated the rural area, the greater the incidence of poverty.
  • The proportion of the non-elderly population covered by private health insurance-predominantly employer-sponsored coverage-falls as county of residence gets more remote. While 74.6 percent of urban residents had private insurance, only 71.5 percent of rural adjacent and 62.6 percent of rural nonadjacent residents had private insurance.
  • To some extent, the shortfall in private coverage in nonadjacent areas is offset by higher rates of public coverage. In nonadjacent areas, 15.5 percent of residents were publicly insured, compared with 11.1 percent in urban areas.
  • Higher rates of public coverage were not, however, sufficient to fully offset the gap in employer-sponsored coverage. As a result, 21.9 percent of nonadjacent residents were uninsured, compared to only 14.3 percent of urban residents. Adjacent areas, with public coverage rates comparable to those in urban areas, had 17.5 percent of their residents uninsured.
  • Lower rates of coverage in rural areas would not necessarily be a problem if rural residents were less likely to need care. Unfortunately, that was not the case nationally. The reported health status of rural residents-especially in nonadjacent counties-appeared worse than that of urban residents. In nonadjacent areas, 13.1 percent of residents reported their health status as fair or poor, compared with 9.6 percent of urban residents and 9.0 percent of adjacent residents.
  • State-level differences in health status did not, however, follow this pattern strongly. In four of the eight states, there were no significant differences between urban and rural areas in the share of population in fair or poor health.
  • Rural residents were significantly less likely to have seen a physician (64.8 percent for nonadjacent areas and 66.5 percent for adjacent areas, compared with 71.6 percent for urban areas) but significantly more likely to have consulted some other type of health professional.
  • In certain states, the problems facing rural residents converge. In Alabama, Mississippi, and Washington, rural residents were significantly more likely than urban residents to suffer a combination of the following: 1) be in fair or poor health, 2) be uninsured, 3) not visit a health care provider, and 4) lack confidence they could get needed care.


IMPLICATIONS

  • The indicators presented in the study point to a clear need for a health care safety net in rural communities.
  • To be successful, policies aimed at securing the rural safety net must take into account the diversity of rural conditions within and across states. Rural-urban differences in access and utilization are not present to the same degree in all of the study states. Rural circumstances in some states are not as severe as the national data suggest, while in other states they are more severe.

"Health Insurance in Rural America" by L. Pol. Rural Policy Brief 5(11). RUPRI Center for Rural Health Policy Analysis. August 2000.


While the percentages of rural and urban uninsured are similar, significant rural-urban differences in employment and income must be considered when crafting policy to address the problem.


OBJECTIVE

To highlight differences in relevant characteristics of the rural and urban uninsured.


DATA

Source: March 1999, Current Population Survey (CPS). U.S. Census Bureau.

Description: Contains 1998 health insurance information for a representative sample of U.S. residents. Survey respondents were asked about their health insurance coverage during the preceding calendar year and were counted as insured if they had health insurance at any time during that period. However, respondents may actually be answering for the point in time at which they were asked. Therefore, the data may describe respondents' status for 1999.

Rural and urban are defined using OMB's metropolitan/nonmetropolitan area designations.


BACKGROUND

As of 1998, the percentages of Americans without health insurance stood at 15.7 percent in rural areas, 16.4 percent in urban. (Whether rural or urban has the higher rate depends upon which survey and which year are used.) Important differences exist, however, between the rural and urban uninsured.


KEY FINDINGS

  • Disproportionately more rural residents than urban rely on individual insurance plans or coverage purchased through small employers.
  • Among rural residents who are employed, a higher proportion than the urban employed is in situations not conducive to moderately priced group health insurance products (i.e., small employers, self-employed individuals, and those in agricultural occupations).
  • The uninsured in rural areas are more likely than those in urban areas to have low or modest incomes.


IMPLICATIONS

  • Efforts to increase insurance coverage in rural areas must be sensitive to the low wages and incomes of rural residents.
  • The absence of large employers in many rural areas necessitates different strategies for aggregating large groups of people to achieve scale economies and avoid problems of adverse risk selection.

"Lengthening Spells of Uninsurance and Their Consequences," by K. Mueller, K. Patil, and F. Ullrich. Rural Health Policy, Vol. 13, No.1. Winter 1997.


In the 1990s, spells of uninsurance in Nebraska had increased from those of the mid-1980s, particularly for residents in rural areas, where the uninsured are also less likely to visit a physician.


OBJECTIVE

To address two basic questions: 1) Are there differences in the length of spells of uninsurance among rural and urban residents? 2) Does the relationship of insurance status to doctor visits vary according to insurance status (including a change in status) and with urban-rural residence?


DATA

Source: Telephone interviews in 1991 of randomly selected households in Nebraska, with a disproportionate probability design to maximize the number of uninsured contacted. These interviews were supplemented by personal interviews and construction of life history calendars in 1992 of a subset of those households.

Description: The data set includes information on persons under age 65 such as household income, household size, age of members, place of residence, employment, insurance status, health status, and health utilization. It also includes a temporal sequence of episodes of insurance, employment, health status, and health utilization.

Urban counties are within an MSA. Rural counties are outside an MSA. Frontier counties are rural counties with fewer than six persons per square mile.


BACKGROUND

Whether an individual has insurance can influence utilization of medical services. In turn, utilization of services can influence health status. The longer the spell of uninsurance, the more likely an individual is to suffer adverse consequences. There are reasons to suspect urban-rural differences in both the length of spells of uninsurance and in access to services during those spells.


KEY FINDINGS

  • Spells of uninsurance were longer in these data than in the national samples from the mid-1980s. The median length was 14 months. Three fourths of the spells lasted at least six months. One fourth of the spells lasted longer than 34 months. (The length of the spells will naturally be prolonged in this data set because a longer time frame is involved-a minimum of five years compared to the 36 months of the SIPP).
  • The length of uninsurance spells increased during the years covered by these data.
  • The longest spells occurred in the rural and frontier counties. The median spell was approximately six months for urban residents, 16 months for rural residents, and 22 months for frontier residents.
  • While the rates of uninsurance may be similar for urban and rural areas, the characteristics of the uninsured are much different.
  • Spells of uninsurance are more likely to end for urban residents for nearly all possible lengths, and overall the hazard rate for ending spells is significantly higher for urban counties.
  • Utilization of medical services during and after spells of uninsurance also varies between urban and rural counties. Overall, there are fewer physician visits among the uninsured.
  • Urban residents decrease physician utilization after gaining insurance, frontier residents increase utilization, and rural nonfrontier residents maintain their existing patterns of utilization.
  • The decrease in utilization for newly insured urban respondents may be a function of 1) their shorter spells meant uninterrupted patterns of care during episodes of uninsurance; 2) increased physician visits at the end of a spell of uninsurance because of availability of care through free clinics and the prospect of a co-payment or deductible with insurance; or 3) pre-existing condition clauses in insurance plans.
  • The increase in utilization in frontier counties may be a function of 1) longer spells of uninsurance and therefore greater likelihood of pent-up demand; 2) greater likelihood of not seeking physician services when they cannot pay, both because of a sense of pride and because there are limited opportunities for free care through clinics; or 3) the expectation of high costs subsequent to a physician visit are not a hindrance to seeking care from lower-cost physicians (compared to urban).


IMPLICATIONS

  • The findings have implications for health care finance reform. The problem of being uninsured is not a temporary one, certainly not a problem of only a few months' duration. Therefore, while insurance reform requiring portability may help some rural residents, it does not address what is close to a permanent status of uninsurance among many rural residents.
  • Efforts to develop health care insurance purchasing cooperatives may be beneficial, especially when individuals can participate, including individuals who have been more or less permanently excluded from insurance options. Such cooperatives, in tandem with publicly supported pools for persons uninsurable due to adverse risk, might help cover the uninsured population.
  • Further research is needed to establish reasons for prolonged spells of uninsurance in rural areas.

"The Role of Uninsurance and Race in Healthcare Utilization by Rural Minorities," by K. Mueller, K. Patil, and E. Boilesen. HSR: Health Services Research, Vol. 33. No. 3. August 1998.

Copyright 1998 by Health Research and Educational Trust. Material excerpted with permission.

Lack of insurance, rural residence, and minority status all combine to lower the utilization of healthcare services.


OBJECTIVE

To examine the independent effects of minority status, residence, insurance status, and income on physician utilization, controlling for general health status and the presence of acute or chronic health problems. Of special interest was the question of utilization differences among rural minority populations, as compared with urban non-Latino whites.


DATA

Source: 1992 National Health Interview Survey, National Center for Health Statistics.

Description: The survey included information about the race/ethnicity of the respondent, health status, utilization of services, insurance status, and socioeconomic status. The study examines the population under age 65.

Rural is defined as nonmetropolitan.


BACKGROUND

While important, the lack of health insurance is not the only, and may not be the prominent, reason for limited access to medical care. Place of residence, especially in health professional shortage areas, creates access problems, as do cultural differences between residents and healthcare providers. Therefore, incremental approaches to dealing with access issues must address problems other than health insurance. Statistical models that test for the relative contributions of various potential barriers can help in the development of policies that might have an optimal effect on improving access.

The principal hypothesis is that certain population groups (rural African American, Latino, Asian, and other) will be less likely to use healthcare services than urban whites, controlling for other population and system characteristics.

KEY FINDINGS

  • Among the variables tested-race, insurance, and residence-insurance has the greatest association with utilization. The uninsured were 60 percent less likely to use services than were the insured.
  • All racial groups and rural whites were less likely to have seen a physician during the previous 12 months than were urban whites.
  • The combination of minority status and rural residence is uniquely related to lower utilization of physician services.
  • The influence of insurance status, combined with the characteristics of residence and ethnicity, lowers considerably the likelihood of seeing a physician.
  • Rural residence actually lowers the likelihood that the uninsured saw a physician during the previous 12 months (except for Latinos), but has the opposite effect for the insured.


IMPLICATIONS

  • Major forces-in this case, health insurance-that are dividing society into different groupings may be more important than more subtle divisions-in this case, eight different groups based on residence and race/ethnicity. Therefore, addressing the problems of cultural subgroups without first addressing the broader problem of health insurance would be an inadequate policy approach.
  • Nevertheless, difference in utilization based on residence and minority status are important. Access for rural Latinos is of special concern. With changes in eligibility for public programs and continuing increases in Latino migration into rural areas, problems of access may be accentuated. Research into those differences and their ultimate consequences on health outcomes should be conducted.
  • Addressing insurance status is important. However, so is addressing the unique problems that minority groups face, especially those groups in rural areas. The circumstances of rural minorities can be addressed through policies to improve their odds of having health insurance, such as economic development policies to improve employment opportunities, as well as policies that help get appropriate healthcare providers to serve rural minorities.


"Patterns of Health Insurance Coverage Among Rural and Urban Children" by A. Coburn, T. McBride, and E. Ziller. Working Paper #26. Maine Rural Health Research Center. November 2001.


Differences among rural and urban children in the patterns of insurance coverage and spells of uninsurance have implications for the design and implementation of programs such as the State Children's Health Insurance Program.


OBJECTIVE

To assess differences in the patterns of insurance coverage and uninsured spells among rural and urban children in 20 states and examine the implications of those differences for the design and implementation of public insurance programs such as S-CHIP.


DATA

Source: 1993 panel of the Survey of Income and Program Participation (SIPP). U.S. Census Bureau.

Description: The 1993 panel was initially interviewed in February 1993 and then was interviewed every four months through January 1996 for a total of nine interviews spanning 36 months. The data set contains detailed socio-demographic information and information on month to month fluctuations in household and individual income, health insurance status, labor force status, and participation in government programs such as Medicare and Medicaid for a nationally representative sample of the U.S. population. The SIPP has data on uninsured children, but the variable indicating whether a child lives in a metropolitan or nonmetropolitan area is only publicly available for the following 20 states in the sample: Arizona, California, District of Columbia, Florida, Georgia, Hawaii, Illinois, Kentucky, Maryland, Massachusetts, Mississippi, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, and Utah.

Rural and urban are defined using OMB's metropolitan/nonmetropolitan area designations.


BACKGROUND

A steady decrease in private health insurance coverage for children during the 1990s left more than 11 million children without coverage in 1998. One-fifth of these children lived in a nonmetropolitan county. In response, Congress created the State Children's Health Insurance Program (S-CHIP). As of January 2000, nearly 2 million children had enrolled in an S-CHIP plan.

However, implementation of the S-CHIP in rural areas may be hampered by a lack of understanding about the patterns of insurance coverage that rural children experience. Differences in the frequency and length of uninsured spells, for example, can affect whether, how, and the degree to which rural children enroll in the program.


KEY FINDINGS

Frequency of Uninsured Spells

  • Rural children were more likely than urban to lack health insurance at a point in time (15.5 vs. 13.8 percent in December 1993 and 14.3 vs. 12.7 percent in December 1994).
  • Rural children were more likely than urban to have had at least one spell of uninsurance during the 36-month period (36.3 vs. 31.1 percent).
  • Rural children were slightly more likely than urban to have single spells; however, rural children were also more likely to have three or more spells (6.9 vs. 5.5 percent).

Duration of Uninsured Spells

  • Comparing the duration of new spells, rural children who lost their coverage during the survey were more likely than urban children to experience both short and long spells.
  • Rural children who lost coverage during the survey were slightly more likely than urban children to have spells that lasted four months or less (50 vs. 47.7 percent), and were more likely to have spells that lasted 17 months or more (9.2 vs. 8.3 percent).
  • The average duration of new spells was shorter for rural children, and regaining coverage quickly seems to be likely for many that lose coverage.
  • Rural children were also more likely than urban children to have protracted spells-77.9 percent of rural children without insurance at a specific point in time remained uninsured for more than a year, as compared to 71.6 percent of uninsured urban children. Moreover, 55 percent remained uninsured for more than two years, versus 51.9 percent of urban children.
  • These findings suggest that chronic uninsurance is a significant problem for a large proportion of rural uninsured children.

Insurance Coverage

  • Rural children had slightly lower rates than urban children of private insurance (63.5 vs. 65.3 percent). The percentage of each with Medicaid coverage was nearly identical.
  • Compared to urban children, rural children were more likely to have a different source of coverage at the beginning and end of spells (e.g., start with private, end with Medicaid).

Characteristics of the Uninsured

  • The characteristics of rural children differed significantly from those of their urban counterparts. Several of those characteristics likely contributed to differences in insurance coverage, some-such as higher proportion of children living in poverty-contributed negatively, others-such as higher proportion living in two-parent families-contributed positively.
  • Looking just at uninsured children, a higher proportion of rural children than urban lived in poverty (28.1 vs. 24.4 percent).


IMPLICATIONS

  • States may face challenges to enrolling rural children and their families in S-CHIP programs. For example, because rural children have shorter new spells of uninsurance, families may be less likely to take advantage of new public programs that have become available. The anticipation of obtaining coverage in the near future may discourage enrollment-especially if application procedures are complex and burdensome. The disincentive will be even higher in states that mandate waiting periods to avoid enticing people away from private insurance.
  • Rural families who lose private coverage appear willing and able to take advantage of public programs. Therefore, strategies to wrap public coverage around private insurance plans could be particularly beneficial to rural children. In states that have created "stand alone" S-CHIP programs it will be particularly important to rural children to ensure smooth transitions between Medicaid and S-CHIP and thereby provide seamless coverage.
  • Policies to address the needs of chronically uninsured children may differ significantly from those that reach short-term rural uninsured children.

"Is the Rural Safety Net at Risk? Analyses of Charity and Uncompensated Care Provided by Rural Hospitals in Washington, West Virginia, Texas, Iowa, and Vermont" by J. Sutton, B. Blanchfield, A. Singer, and M. Milet. Project HOPE Walsh Center for Rural Health Analysis. January 29, 2001.


The provision of charity and uncompensated care by rural hospitals varies dramatically across states and may not be as dependent as previously believed upon hospital financial health.


OBJECTIVE

To examine trends in hospital charity care and identify hospital characteristics associated with greater provision of charity and uncompensated care. To determine the relationship between hospital financial health and charity care. To identify rural communities that may be vulnerable if their hospitals are unable to continue to provide previous charity care levels.


DATA

Source: Hospital audited financial statements for 1996, 1997, and 1998.

Description: Data on hospitals in 246 rural counties across five states-Iowa, Texas, Vermont, Washington, and West Virginia. A hospital-level analytical file was created by linking each hospital's name and address to data from the 1997 HCFA Provider of Service file, the 1997 HCFA Impact File, and the 1998 BHP Area Resource File.

Uncompensated care is defined as the sum of charity care and bad debt. Charity care represents the costs of care given without expectation of payment; bad debt represents the costs of care give for which payment was expected but not received.


BACKGROUND

Rural hospitals, which often serve as informal safety nets for the uninsured in their communities, are especially vulnerable to payment changes legislated in the Balanced Budget Act of 1997 (BBA), many of which are expected to reduce the flow of revenue to rural hospitals and their affiliates. This may make it difficult for rural hospitals to remain financially healthy while continuing to provide charity care.

KEY FINDINGS

  • Contrary to the initial hypothesis, hospitals' financial health did not appear to have a significant effect on levels of charity care provided or uncompensated care expenditures.
  • On average, charity and uncompensated care rendered by short-term rural hospitals in each of the five states in the study paralleled indicators of need and reflected state health policies.
  • Approximately 17 percent of the 246 rural counties in the study were at risk of losing access to local hospital services since all hospitals in the counties reported an average 3-year negative total margin. Iowa and Washington had the lowest percentages of at-risk counties; Texas had the highest.
  • Across states, the disproportionate share percentage and ownership were the most important hospital characteristics associated with individual levels of charity and uncompensated care.
  • Rural hospitals that treat a high proportion of low-income patients (measured by DSH) provided significantly more charity and uncompensated care than other hospitals.
  • For-profit hospitals in these five states provide less charity care and uncompensated care than non-profit hospitals.


IMPLICATIONS

  • Further research is needed to fully understand the nature and direction of the relationship between financial performance and hospital expenditures on charity and uncompensated care. The research should use nationally representative, hospital-level data, and statistical models that account for the potentially endogenous relationship between financial performance and charity and uncompensated care.
  • The differences in the numbers of at-risk counties between states may be due to the generosity of state public insurance. In states with restrictive public insurance eligibility and coverage requirements, hospitals may be forced to assume a greater financial burden for the indigent population through uncompensated and charity care.
  • It will be essential to monitor the development of the revised DSH formula to ensure that rural hospitals are not adversely impacted and to guarantee that resources are available to enable rural safety net hospitals to continue to provide services in their communities.

How Many Uninsured? A Resource Guide for Community Estimates, by E. Socholitzky and N. Turnbull. The Access Project. June 1999.


Helping local groups obtain data on the uninsured.


OBJECTIVE

To help community groups collect useful and defensible data on the number of uninsured people in their communities.


DATA

N/A

BACKGROUND

With the failure of national health reform, responsibility to improve access to health care has shifted not only to states, but also to local communities. In order for these communities to assess healthcare policies and develop strategies, they must be able to collect and use various data, including data on the uninsured.


KEY FINDINGS

  • Chapter 1 describes the rationale for collecting data on the number of uninsured people.
  • Chapter 2 discusses challenges and caveats in the use of data.
  • Chapter 3 asks a series of questions that help determine the best approach in getting data.
  • Chapter 4 describes various existing data sources and discusses their strengths and weaknesses.
  • Chapter 5 provides a brief discussion on collecting data through surveys.
  • Chapter 6 explains how to get help with data from universities.
  • Chapter 7 presents several case studies of successful data collection efforts by community organizations.
  • Chapter 8 lists various resources, including governmental and nongovernmental agencies.
  • Appendices provide sample surveys and additional information.


IMPLICATIONS

N/A


Abbreviations

BBA Balanced Budget Act of 1997
BHP Bureau of Health Professions
BRFSS Behavioral Risk Factor Surveillance System
CHIP Children's Health Insurance Program
CPS Current Population Survey
CTS Community Tracking Study
DSH Disproportionate Share
HCFA Health Care Financing Administration
HMO Health Maintenance Organization
MEPS Medical Expenditure Panel Survey
MSA Metropolitan Statistical Area
NHIS National Health Interview Survey
NSAF National Survey of America's Families
OMB Office of Management and Budget
S-CHIP State Children's Health Insurance Program
SIPP Survey of Income and Program Participation
USDA United States Department of Agric


  


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