Thomas M. Selden

Background: Veteran access to care is an important policy issue that has not previously been examined with population-based survey data. Objectives: This study compares access to care for nonelderly adult Veterans versus comparable non-Veterans, overall and within subgroups defined by simulated eligibility for health care from the Veterans Health Administration and by insurance status. Research Design: We use household survey data from the Medical Expenditure Panel Survey from 2006 to 2011. We use iterative proportional fitting to standardize (control for) differences in age, sex, income, medical conditions, disability, Census region, and Metropolitan Statistical Area. Subjects: Nonelderly Veterans and comparable non-Veterans. Measures: For medical, dental, and prescription medicine treatments, we use 4 access measures: delaying care, inability to obtain care, perceiving delay as a big problem, and perceiving inability to obtain care as a big problem. We also examine having a usual source of care. Results: Frequencies of access barriers are similar for nonelderly Veterans and comparable non-Veterans for dental and prescription medicine treatments. For medical treatment, we find that Veterans eligible for VA health care and Veterans with VA use who are uninsured report fewer access problems than the comparable non-Veteran populations for 2 measures: inability to obtain care and reporting inability to obtain care as a big problem. Conclusions: Our results show that uninsured Veterans, the most policy-relevant group, have better access to care than comparable non-Veterans. Our results highlight the importance of adjusting Veteran and non-Veteran comparisons to account for the higher than average health care needs of Veterans.

To examine the within-year concentration of family health care and the resulting exposure of families to short periods of high expenditure burdens. Household data from the pooled 2003 and 2004 Medical Expenditure Panel Survey (MEPS) yielding nationally representative estimates for the nonelderly civilian noninstitutionalized population. The paper examines the within-year concentration of family medical care use and the frequency with which family out-of-pocket expenditures exceeded 20 percent of family income, computed at the annual, quarterly, and monthly levels. On average among families with medical care, 49 percent of all (charge-weighted) care occurred in a single month, and 63 percent occurred in a single quarter). Nationally, 27 percent of the study population experienced at least 1 month in which out-of-pocket expenditures exceeded 20 percent of income. Monthly 20 percent burden rates were highest among the poor, at 43 percent, and were close to or above 30 percent for all but the highest income group (families above four times the federal poverty line). Within-year spikes in health care utilization can create financial pressures missed by conventional annual burden analyses. Within-year health-related financial pressures may be especially acute among lower-income families due to low asset holdings.

Rapidly rising spending has prompted debate about increasing cost sharing in Medicaid and the Children’s Health Insurance Program (CHIP). In this paper we assess the role of cost sharing in Medicaid and the CHIP and its potential financial burden on low-income families with children. We find that many families would face high health spending burdens even with minimal cost sharing for their publicly insured children. Adding even modest cost sharing for such children could greatly increase high financial burdens. Our results also suggest that implementing income-based caps on family spending can help address the burden of high spending for low-income families.

Previous analyses of families with high health care expenditure burdens have ignored the potentially mitigating effects of tax subsidies. This analysis uses data from the Medical Expenditure Panel Survey (MEPS) to fill this gap. A range of health expenditure burden measures are computed, with and without tax subsidies, showing the impact that tax subsidies have on both the prevalence and magnitude of high health care spending burdens among the nonelderly.

U.S. health care spending is projected to approach $2.4 trillion in 2008; a large share will be paid by government outlays and tax subsidies. Other countries routinely conduct incidence analyses of public health care spending, yet we know of no recent and comprehensive incidence studies for the United States. We examined data for 2002 from the Medical Expenditure Panel Survey aligned to the National Health Expenditure Accounts and augmented with simulated tax subsidies. The public sector accounted for 56.1 percent of health spending within the civilian noninstitutionalized population. Our analysis highlights this sector’s role in financing the care of seniors and people in poor health.

OBJECTIVES. This study examines national compliance rates with well-child visit recommendations using the Medical Expenditure Panel Survey. The Medical Expenditure Panel Survey provides nationally representative information on preventative care for children, combining visit-level data over a 2-year period with a rich array of socioeconomic and health status measures. METHODS. Visit-level data from 2000 to 2002 were used to construct a well-child visit “compliance” measure equal to well-child visits as a percentage of age-specific recommendations from the American Academy of Pediatrics. Compliance was examined across age, gender, race/ethnicity, health status, poverty, insurance coverage, eligibility for public coverage, family structure, parent education, insurance, citizenship and country of origin, language, urbanicity, and census division. RESULTS. On average, 56.3% of all children aged 0 to 18 years had no well-child visits during a 12-month period, and 39.4% had no well-child visits over a 2-year period. The average compliance ratio was 61.4%. Large differences in compliance exist among children. High compliance rates were observed among infants (83.2%), children with special health care needs (86.6%), children with college-educated parents (74.3%), children with family incomes >4 times the poverty level (71.6%), and children in the New England (94.6%) and Middle Atlantic (83.2%) census divisions. Low levels of compliance were observed among uninsured children (35.3%) and especially uninsured children simulated to be eligible for public coverage (28.4%). Other groups with low compliance rates include teenagers (49.2%), noncitizen children (43.9%), and children in the West South Central (44.9%), East South Central (48.8%), and Mountain (49.7%) census divisions. CONCLUSIONS. Well-child visit compliance in the Medical Expenditure Panel Survey is less than found in other househould surveys, yet consistent with or above results based on data from provider and claims data. Although experts dispute the optimal frequency of well-child visits, the disparities observed in compliance rates among population subgroups raise important public health concerns.

Employment-related health insurance is subsidized through exemptions from federal and state income taxes, as well as from taxes for Social Security and Medicare. Proposals to modify this subsidy are a perennial subject of policy debate. We present tax-subsidy projections from a new data resource constructed using a statistical linkage between the establishment and household components of the Medical Expenditure Panel Survey (MEPS). We project that the total federal and state tax subsidy in 2006 for employment-related coverage of active workers will exceed 200 billion dollars. We present per worker tax-subsidy estimates and an analysis of insurance incidence by establishment characteristics.

We examine the relationship between health insurance coverage and children's access to and utilization of medical care. Access measures we study are having a usual source of care (USC) and lacking a USC for financial or insurance reasons. We also examine indicators for ambulatory visits, well-child visits, dental visits, emergency room use, and inpatient hospital stays. We pool data from the first 7 years of the Medical Expenditure Panel Survey (MEPS), 1996 to 2002. Pooling yields a large sample of children, enabling us to analyze access and utilization using simple descriptive statistics, multivariate analysis, and instrumental variables estimation (IV). IV estimation is of particular interest given the possibility of bias caused by confounding factors (such as child health or parent attitudes) and measurement error in insurance coverage. We also compare estimates from IV linear probability models to estimates from IV probit with residual inclusion. As previous studies have found, public and private coverage are both associated with large increases in access and utilization. Simple mean comparisons suggest that private coverage has a larger effect than does public coverage. Differences between public and private coverage are reduced (and often reversed) when we control for other characteristics of children and their families. IV coverage effect estimates from both linear probability and residual inclusion probit models are substantially greater than conventional estimates across a wide range of access and utilization measures. Despite concerns that conventional estimates overstate the impact of coverage on access and use, our results suggest that the reverse may be true. One explanation may be that conventional estimates are biased toward zero due to error in the reporting of insurance coverage. The magnitude of the coverage effects we find highlights the importance of reducing uninsurance among children.

A growing body of research demonstrates the many benefits of expanded public coverage for children. Expansions in Medicaid and the State Children's Health Insurance Program (SCHIP) have helped to increase insurance coverage, increase access to care, and reduce the financial burdens facing low-income families. Less attention has been focused on the cost of expanding public coverage. We argue that budgetary data may exaggerate the net costs of these expansions because many of the highest-cost children would have received publicly funded care even if the expansions had not taken place. Using data from the 2000 Medical Expenditure Panel Survey, we simulate the net cost of SCHIP, finding that the true cost of this program–both to states and to the federal government–is substantially less than average spending per enrollee would suggest. Our results strengthen the benefit-cost argument against implementing rollbacks in SCHIP.

Data from the 1996 Medical Expenditure Panel Survey (MEPS) reveal that 4.7 million children were eligible for Medicaid but were uninsured. Numerous changes have occurred in the landscape for children’s health insurance since then, including welfare reform and implementation of the State Children’s Health Insurance Program (SCHIP). We use data from the 1996–2002 MEPS to track changes in the eligibility and coverage of children. As of 2002, uninsurance among children remained as much a problem of participation as one of eligibility. Nevertheless, we find evidence of dramatic improvements in program participation, reflecting the success of efforts to improve outreach, simplify enrollment, and increase retention.