Contrary to Fears, the Newly Insured Did Not Use More Services Than Others
From 1991 to 1995, researchers at the University of Southern Maine, Human Services Development Institute compared health care utilization rates between previously uninsured and previously insured persons enrolled in state-sponsored insurance programs.
The study sought to inform the debate, in the early 1990s, on the merits of universal health insurance coverage particularly the concern of insurers' that the uninsured population would use health care services at a disproportionately higher rate, thereby increasing the costs.
- Researchers found that previously uninsured, low-income individuals used health care services at the same rate as or slightly lower rates than commercially insured individuals in the same health plan.
- Analysis showed some small some small differences in health care utilization patterns for the previously uninsured.
RWJF supported this project through a grant of $594,099.
When the merits of universal health insurance coverage were under debate in the early 1990s, insurers expressed concern that the uninsured population would use health care services at a disproportionately higher rate, thereby increasing the costs.
This three-year research study compared health care utilization rates between previously uninsured and previously insured persons enrolled in state-sponsored insurance programs. It examined state-subsidized demonstration programs in Maine and Washington, looking for differences in utilization rates, health status, and disenrollment patterns. The researchers also evaluated the effect of prior insurance status and plan cost-sharing features on the use of health services and disenrollment patterns for these two groups.
The Maine demonstration targeted persons working in small businesses (fewer than 15 employees) that did not offer health insurance. The state subsidized premiums on a sliding scale for individuals with incomes at or below 200 percent of the federal poverty level. Companies covered half the premium; the state and the employee shared the remaining cost. The Washington program targeted individuals in the state with incomes up to 200 percent of the federal poverty level, regardless of their employment status. Subsidized premiums ranged from a low of $7 to a high of about $325 per month, with the state carrying the full burden of the subsidy.
Previously uninsured, low-income individuals used health care services at the same rate as or slightly lower rates than commercially insured individuals in the same health plan. In addition to this major finding, the analysis showed some small differences in health care utilization patterns for the previously uninsured:
- In Maine, the previously uninsured had significantly fewer hospital admissions than the insured comparison group. However, emergency room use was somewhat higher for the previously uninsured.
- There were no significant differences in health risk factors between the previously uninsured and the commercially insured groups. This finding is based on telephone interviews conducted with both groups.
- The previously uninsured group had a slightly higher level of self-reported pre-existing conditions, but it was not significant enough to make a difference in health care use.
Because both the Maine and Washington demonstrations required enrollees to pay a premium and operated on a voluntary-enrollment basis, the study findings cannot be generalized to a program of universal coverage. The principal investigator, Elizabeth H, Kilbreth, M.H.S., noted that parameters of these two state-sponsored program may have attracted a subset of the uninsured population that does not differ from the traditional insured population. "There are many individuals who are uninsured solely because of financial barriers. When you dismantle those barriers, that group is interested in enrolling just for the security of having coverage, not necessarily to use services."
The researchers noted other findings that were more a byproduct of the research methodology, itself, than part of the original scope of the study:
- The telephone interview completion rate for the previously uninsured group was lower than expected, reflecting the highly mobile nature and transitory employment and living situations of this population. The researchers found that phones had been disconnected and residents had left no forwarding addresses.
- The Washington demonstration program elicited more participation and more rapid participation than the Maine program, although both states mounted aggressive marketing campaigns. Kilbreth attributes Washington's relative success to two factors: (1) enrollees did not have to rely on employers or being employed to participate; and (2) the program received a substantial amount of state funding and, therefore, did not need to rely on employer subsidies.
An article was published in Advances in Health Economics and Health Services Research, and another article is pending publication in Inquiry.
GRANT DETAILS & CONTACT INFORMATION
Pilot Study on Measuring Health Care Use Among the Low-Income Uninsured
University of Southern Maine, Human Services Development Institute (Portland, ME)
Dates: February 1991 to July 1991
Dates: November 1991 to March 1995
Project Director: Elizabeth Kilbreth, M.H.S.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Kilbreth EH, Coburn AF, McGuire C, Martin DP, Diehr P, Madden CW and Skillman SM. "State-Sponsored Programs for the Uninsured: Is There Adverse Selection?" Inquiry, 35(3): 25065, 1998. Abstract available online.
Kilbreth EH and McGuire C. "State Choices for Voluntary Health Reform Initiatives." Advances in Health Economics and Health Services Research, 15: 125, 1995.
Martin DP, Anderson AB, Diehr P, et al. "Use of Services by New Members in an HMO: Washington's Basic Health Plan vs. Employer Contracts." Unpublished.
Kilbreth EH. The Impact of Program Eligibility Criteria on Recipient Access and Continuity of Care. Dissertation. 1995.
Presentations and Testimony
Health Care Utilization Among the Previously Uninsured. Presented at the Association for Health Services Research, Atlanta, June 1996.
Comparison of Access Initiatives Impact on the Uninsured. Presented as poster session at AHCPR/HRSA National Research Service Award Trainee Conference, June 1995.
Report prepared by: Karin Gillespie
Reviewed by: Marian Bass
Reviewed by: Molly McKaughan
Program Officer: Nancy L. Barrand