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:
- 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.
- 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.
- 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.
- 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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