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The three distinct health-insurance markets in which people can obtain health insurance, an the special nature of competition among insurance companies in the non-group market are described. The case is made for government to act as reinsurer and assume the risk of extremely high-cost people. Efficiency in the non-group health-insurance market would be improved if the government reinsured the market. Equity also would be increased if the government acted as reinsurer because more uninsured people would have access to insurance. Finally, the precedents for this role for government in other markets, and why tax-related subsidies will not succeed in increasing health-insurance coverage unless the risk of extremely high costs are shifted to the government are described.

The persistently large number of uninsured, roughly 40 million per year since 1993, continues to elicit bipartisan policy interest. Coverage-expansion proposals without mandates, by far the most common since the defeat of the Clinton plan, must address risk-pooling realities in private markets. Insurers have strong financial incentives to segment risks and minimize pooling of heterogeneous risks, and narrow risk-pooling will diminish the adequacy of premium subsidies based on income alone, at lest for higher-risk individuals. The current debate over flat tax credits and the non-group market is a case in point. The paper develops a proposal that would expand coverage in a large and creative way. The proposal developed would subsidize low-income individuals and families but also addresses the issue of inefficient and inequitable risk-pooling.

This paper discusses the issues surrounding the criteria along which alternative approaches to reform can be evaluated. The paper presents microsimulation estimates of the impacts of three types of reforms: tax credits for individual purchase of nongroup insurance, expansions of public insurance to children and parents, and expansion of public insurance to all adults. The results from the simulations are used to contrast these reforms using the various criteria developed in the paper.

In autumn 2000, the World Bank's board approved the first ever strategy for the new social protection and labor sector, and in January 2001, the sector published the strategy. The subtitle, from safety net to springboard, indicated the World Bank's move toward a broader understanding of poverty reduction and the relationship of risk to poverty. Because risks and access to appropriate risk management instruments matter for poverty reduction and development, the strategy proposed a new conceptual framework - social risk management that will review and reform existing interventions and propose new ones to better assist the vulnerable in addressing the many risks to which they are exposed. After seven years of implementation, it was time to review the strategy and work of the areas of selected core competence: labor market, social insurance (in particular pensions), social safety nets, social funds, disability and development, and risk and vulnerability analysis. The strategic position, its development, and the results by the sector since the launch of its strategy were reviewed and presented to the World Bank's committee on development effectiveness at the end of 2007. The review included a stocktaking of the analytical work and lending operations in each of the six core competence areas. The result of this review and the six stocktaking papers are presented in this publication. They reveal the progress that the World Bank has made in understanding the importance of social risk management for poverty reduction and the critical contribution it makes to equitable and sustainable growth.

Reveals the roots of America's failure to address the health care need of its citizens. In a comprehensive history of the failed efforts to enact universal insurance from the 1940s to the 1990s, the author shows how each attempt to enact national health insurance has met with fierce attacks by stakeholders

ABSTRACTObjectivesTo investigate whether health insurance generated improvements in cardiovascular risk factors (blood pressure and hemoglobin A1c (HbA1c) levels) for identifiable subpopulations, and using machine learning to identify characteristics of people predicted to benefit highly.DesignSecondary analysis of randomized controlled trial.SettingMedicaid insurance coverage in 2008 for adults on low incomes (defined as lower than the federal-defined poverty line) in Oregon who were uninsured. Participants12 134 participants from the Oregon Health Insurance Experiment with in-person data for health outcomes for both treatment and control groups.InterventionsHealth insurance (Medicaid) coverage.Main outcomes and measuresThe conditional local average treatment effects of Medicaid coverage on systolic blood pressure and HbA1c using a machine learning causal forest algorithm (with instrumental variables). Characteristics of individuals with positive predicted benefits of Medicaid coverage based on the algorithm were compared with the characteristics of others. The effect of Medicaid coverage was calculated on blood pressure and HbA1c among individuals with high predicted benefits.ResultsIn the in-person interview survey, mean systolic blood pressure was 119 (standard deviation 17) mmHg and mean HbA1c concentrations was 5.3% (standard deviation 0.6%). Our causal forest model showed heterogeneity in the effect of Medicaid coverage on systolic blood pressure. Individuals with lower baseline healthcare charges, for example, had higher predicted benefits from gaining Medicaid coverage. Medicaid coverage significantly lowered systolic blood pressure (−2.93 mmHg (95% confidence interval −5.82 to −0.32)) for people predicted to benefit highly. No evidence showed that Medicaid coverage lowered HbA1c for people with high predicted benefits.ConclusionsAlthough Medicaid coverage did not improve cardiovascular risk factors on average, improvements were noted in blood pressure among a subset of individuals with higher predicted benefits. These individuals were more likely to have no or low prior healthcare charges, for example. The findings suggest that Medicaid coverage leads to improved blood pressure for some people, but those benefits may be diluted by individuals who did not benefit. Although the effect size may be of limited clinical significance for any individual, at a broad population level that includes individuals who are both hypertensive and normotensive, the findings may be of public health importance for policy interventions.

Objectives. To document how health insurance coverage changed for White, Black, and Hispanic adults after the Affordable Care Act (ACA) went into effect. Methods. We used data from the American Community Survey from 2008 to 2014 to examine changes in the percentage of nonelderly adults who were uninsured, covered by Medicaid, or covered by private health insurance. In addition to presenting overall trends by race/ethnicity, we stratified the analysis by income group and state Medicaid expansion status. Results. In 2013, 40.5% of Hispanics and 25.8% of Blacks were uninsured, compared with 14.8% of Whites. We found a larger gap in private insurance, which was partially offset by higher rates of public coverage among Blacks and Hispanics. After the main ACA provisions went into effect in 2014, coverage disparities declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites. Coverage gains were greater in states that expanded Medicaid programs. Conclusions. The ACA has reduced racial/ethnic disparities in coverage, although substantial disparities remain. Further increases in coverage will require Medicaid expansion by more states and improved program take-up in states that have already done so.

A steady decline in cervical cancer incidence and mortality in the United States has been attributed to increased uptake of cervical cancer screening tests such as Papanicolau (Pap) tests. However, disparities in Pap test compliance exist, and may be due in part to perceived barriers or lack of knowledge about risk factors for cervical cancer. This study aimed to assess correlates of cervical cancer risk factor knowledge and examine socio-demographic predictors of self-reported barriers to screening among a group of low-income uninsured women. Survey and procedure data from 433 women, who received grant-funded cervical cancer screenings over a span of 33 months, were examined for this project. Data included demographics, knowledge of risk factors, and agreement on potential barriers to screening. Descriptive analysis showed significant correlation between educational attainment and knowledge of risk factors (r = 0.1381, P < 0.01). Multivariate analyses revealed that compared to Whites, Hispanics had increased odds of identifying fear of finding cancer (OR 1.56, 95 % CI 1.00–2.43), language barriers (OR 4.72, 95 % CI 2.62–8.50), and male physicians (OR 2.16, 95 % CI 1.32–3.55) as barriers. Hispanics (OR 1.99, 95 % CI 1.16–3.44) and Blacks (OR 2.06, 95 % CI 1.15–3.68) had a two-fold increase in odds of agreeing that lack of knowledge was a barrier. Identified barriers varied with age, marital status and previous screening. Programs aimed at conducting free or subsidized screenings for medically underserved women should include culturally relevant education and patient care in order to reduce barriers and improve screening compliance for safety-net populations.

Background Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Although a number of CRC screening tests have been established as being effective for CRC prevention and early detection, rates of CRC screening test completion in the US population remain suboptimal, especially among the uninsured, recent immigrants and Hispanics. In this study, we used a structural equation modelling approach to identify factors influencing screening test completion in a successful CRC screening program that was implemented in an uninsured Hispanic population. This information will enhance our understanding of influences on CRC screening among historically underscreened populations. Methods We used generalized structural equation models (SEM) utilizing participant reported information collected through a series of surveys. We identified direct and indirect pathways through which cofactors, CRC knowledge and individual Health Belief Model constructs (perceived benefits, barriers, susceptibility, fatalism and self-efficacy) and a latent psychosocial health construct mediated screening in an effective prospective randomized CRC screening intervention that was tailored for uninsured Hispanic Americans. Results Seven hundred twenty-three participants were eligible for inclusion; mean age was 56 years, 79.7% were female, and 98.9% were Hispanic. The total intervention effect was comparable in both models, with both having a direct and indirect effect on screening completion ( n  = 715, Model 1: RC = 2.46 [95% CI: 2.20, 2.71, p  < 0.001]; n  = 699, Model 2 RC =2.45, [95% CI: 2.18, 2.72, p  < 0.001]. In Model 1, 32% of the overall effect was mediated by the latent psychosocial health construct (RC = 0.79, p  < 0.001) that was in turn mainly influenced by self-efficacy, perceived benefits and fatalism. In Model 2, the most important individual mediators were self-efficacy (RC = 0.24, p  = 0.013), and fatalism (RC = 0.07, p  = 0.033). Conclusion This study contributes to our understanding of mediators of CRC screening and suggests that targeting self-efficacy, perceived benefits and fatalism could maximize the effectiveness of CRC screening interventions particularly in Hispanic populations.

Insurance transitions-sometimes referred to as \"churn\"-before and after childbirth can adversely affect the continuity and quality of care. Yet little is known about coverage patterns and changes for women giving birth in the United States. Using nationally representative survey data for the period 2005-13, we found high rates of insurance transitions before and after delivery. Half of women who were uninsured nine months before delivery had acquired Medicaid or CHIP coverage by the month of delivery, but 55 percent of women with that coverage at delivery experienced a coverage gap in the ensuing six months. Risk factors associated with insurance loss after delivery include not speaking English at home, being unmarried, having Medicaid or CHIP coverage at delivery, living in the South, and having a family income of 100-185 percent of the poverty level. To minimize the adverse effects of coverage disruptions, states should consider policies that promote the continuity of coverage for childbearing women, particularly those with pregnancy-related Medicaid eligibility.