How Medical Insurance Impacts Access to Health Care in the United States

Without Insurance Access to Health Care is Limited in the United States
Why the Insurance Model Was Chosen for Increasing Health Care Access
One of the things I learned while a student at the School of Public Health and Community Medicine was that people who lacked health insurance also lacked reliable health care. Let us review some of the national data in this regard. In my fifty-state analysis I reviewed the following components for individual health care measures: evidence of employer based health insurance, the state uninsured population, infant mortality and other clinical outcomes. Listed below are the top performers for the criteria, as well as the laggards.

States with the Highest Levels of Health Insurance, Public or Private
Using the latest Kaiser Family Foundation Insurance Survey , the 2010 results show the number one state for health insurance coverage is Massachusetts, with 95% reporting health insurance plans. Massachusetts has been the model for the national insurance exchanges because its state mandate has achieved near universal coverage and is self supporting. Other states deserving honorable mention for securing health insurance for 90% of their residents include: Hawaii, Vermont, and Wisconsin.

States with the Lowest Levels of Health Insurance, Public or Private
Women ages 19-64
In the same survey, the worst state for provision of medical insurance either public or private was Texas, with only 70% of its women reporting medical insurance coverage. The national average for insured women was 80% at the time of the survey. Florida reported that 74% of its adult women had medical coverage. A host of states reported only 75% of their adult female populations had medical insurance including: Arkansas, Mississippi, Nevada, and New Mexico.
Men ages 19-64
The national average for men with medical insurance was 76% by 2010. For Texas men only 65% had medical insurance. Other low fliers for men with medical insurance were: Georgia (71%), New Mexico (67%), and Florida (69%).
Children <18
Across the nation only 50% of our children had health insurance provided through their parent’s place of work. Though 90% of the nation’s children have medical insurance now, 36% of that figure is provided by public programs like Medicaid. For the children’s health survey, Texas also posted an equally poor level of insured children, the lowest in the nation, with 17% of the state’s children lacking medical insurance. This is despite the federally subsidized Children’s Health Insurance Program, so is Texas failing to enroll its children or are their parents making too much money to qualify?
Other states with high levels of an uninsured children included Florida (16%), Nevada (16%), and Arizona (15%). You would think Nevada could come up with something creative like a gambling tax to subsidize health insurance for its residents. Why do some of these states have so many more children without health insurance?
Cost of Deferred Health Care
Since the United States has chosen to finance its health care through a public and private system, the lack of payment for services for the uninsured gets allocated to hospitals and insurance plans. The federal insurance mandate is an attempt to stave the high costs for hospitals and communities from serving the uninsured population. Those states with higher levels of uninsured individuals mean that more health care is either delayed or delivered in emergency settings. Additionally, uninsured patients are not receiving preventive or basic health care. States that are laissez faire place a disproportionate burden on their hospitals to serve uninsured patients and this impacts the overall health care safety net.
Clinical Outcomes
If evidence of insurance is a factor in securing better health care, let’s see what the clinical data shows for these states. Infant mortality is an indication of prenatal and postnatal care and here are the infant deaths per 1,000 babies for the states with high levels of insurance, versus the low levels. These infant mortality rates are drawn from the 2009 Kaiser Foundation Survey. Infant mortality is just one measure of childhood health, but in adherence to brevity I am not going to list the other metrics I used in my full scorecard evaluation.
Infant Mortality
Best in class for both percentage of the population covered for insurance (95%) and the lowest infant mortality rate in the nation at 4.9 deaths is Massachusetts. Way to go mother Mass! This makes their prenatal and postnatal care equal to most of Europe, which is a high standard. And here is how the other well-insured states ranked for infant mortality per 1,000 babies: Hawaii-6.1 deaths, Vermont-5.6, and Wisconsin-6.3. Now let us compare this metric to the states which reported the lowest levels of children with health insurance and here are the infant deaths per 1,000: Texas-6.3, Florida- 7.2, Nevada-6.2, and Arizona-6.6. When you compare the average infant mortality of the states with higher insurance levels to those without, there is a difference of nearly one life per 1,000 babies, which is significant. Also, in case you don’t know, the United States infant mortality rate on average is 47th in the world, behind all of Europe and most of the developed world. And if you don’t already feel bad enough, some countries, including Singapore boast an infant mortality rate which is one third of the U.S. average at 2.31 deaths per 1,000 babies.

As we listen to the harping about Americans not having a right to basic health care, bear in mind that the United States has the highest percentage of children living in poverty in the industrialized world, at nearly one fourth (24%) of our child population. You have to ask yourself, what do our nation’s children have a right to in this wealthy country?

For more information on 50-state performance metrics come to the Northwest Women’s Show on March 2nd to hear excerpts from my book, Unraveling U.S. Health Care.

This article was written by Robert E. Winter, MHA, MPA and may be reprinted with her permission, but feel free to share it virally.

Rolling Back The Clock On Women's Health Care

Impact of the Vatican's Universal Translation of Faith, Catholic Owned Health Care Facilities and State Legislation on Health Care for Women
The triad of the new stricter Vatican rules for interpretation of Catholic protocols, the trend toward Catholic organizations purchasing non-Catholic hospitals, and the furor over the proposed women's health standards for the 2014 health insurance exchanges have made this a topic which must be revisited. In order of appearance here are the players:the Vatican, Swedish Health Services, and the State of Mississippi.

Vatican Rules on a Universal Translation for Catholics
Beginning November 27, 2011, the Vatican has issued another edict which attempts to tighten the interpretation of the Catholic faith, by mandating a single universal translation of the faith. The church hopes to reign in the more liberal interpretation which is prevalent in the United States and other western countries. Though one might think this only affects Catholics, not-so-fast, it affects all Catholic Church owned enterprises, including hospitals and schools, which serve an interfaith community and that brings us to our next player.

Swedish Health Services Acquiescence to the Catholic Entity Providence Health
Counter-intuitive to the trend of Catholic hospitals purchasing non-Catholic facilities throughout the United States, the secular hospital group, Swedish Health Services has acquired Providence Health Services hospital and clinics. However, what is most interesting about this transaction is the Pope still got his way, as the deal is subject to his approval, and he has mandated a line-item-veto on the secular facility’s ability to provide abortions. One could understand a Catholic hospital which did not wish to provide abortions, but Swedish is a secular institution and it is acquiring Providence. Though Swedish has indicated this wouldn’t have a huge impact on the service for women in the Puget Sound area of Washington State, they did not have any public hearings about this reduction in service. Clinically, there are cases where women may require a hospital facility for an abortion, but that doesn’t seem to matter here. At least in the Seattle area there are other secular facilities which will provide the service. It is important to note that the Vatican has specifically addressed the elective abortions, which can include victims of rape or incest. I am sure these women consider their legal health concerns to be paramount and hardly “elective.” Apparently there is no due process required if it concerns female reproductive rights, even in the highly secular community of Seattle, where Swedish is based. The fact that we have allowed our health care practice to be determined by a celibate male from another country offends not only me, but also the majority of residents.

According to a 2005 report by Catholics for a Free Choice , there are 60 Catholic health care systems located in all 50 states in the United States. One of the concerns about Catholic hospitals is do they restrict health services? This question applies not only for reproductive rights, but also for advanced medical directives for patients who wish to die without certain medical interventions. According to a 2006 survey by Pew Research Council, 70% of Americans felt that patients should sometimes be allowed to die, 70% also indicated they would rather die at home, than in a prolonged artificially extended manner in the hospital. Only 22% of those polled said that life should be prolonged using extraordinary measures. The majority of Americans shun the loss of dignity while being kept alive mechanically, but would a Catholic hospital respect their wishes? The nonprofit group Catholics for a Free Choice, states that Catholic hospitals do restrict health care services based on the edicts of the Vatican via the Ethical and Religious Directives for Catholic Health Care. It should be obvious that non Catholic patients as well as Catholics may disagree with these practices, so it behooves the patient to verify any service restrictions in policy and in practice in advance of treatment in a Catholic facility. Unfortunately, for many people in America this is not an option, as the only hospital in their area may be a Catholic institution, which has an impact on end-stage-of-life-care and other health services decisions.

Mississippi is Close to Defining Life as at the Point of Conception
Previously I have written about my 50-state analysis of the 2010 health care mandates for the regional insurance purchasing cooperatives, including the incendiary furor over women’s reproductive autonomy. Not to be outdone in its leap to the dark ages, the State of Mississippi is close to passing a law which defines human life as beginning at the moment of conception. Needless to say, this will be a sticky wicket when it comes to actually, catching-someone-in-the-act. The personhood law, if it passes will make it a crime for a woman to obtain an abortion at all, as the life of the fetus will supersede that of the woman who is already alive and kicking. Additionally, this “chastity belt” would also outlaw the use of certain birth control devices, including IUD’s which are intrauterine devices that allow fertilization but prevent embryo attachment to the uterine wall. Of course, the morning after pill would not be allowed either. Going a step further than just the birth canal, the destruction of any in vitro fertilized eggs would also be a crime.
The proposed law certainly cuts a wide swath across those who are fertile and those who may have fertility challenges. This state could potentially institutionalize pregnant women to enforce delivery and likewise for rape victims or incest victims. More to the point, for those fertile lasses who have already had several children while using various birth control measures, and decide they cannot afford more children, they would become criminals. It will be interesting to see how this one winds its way through the courts, if it passes the legislature.
Lest you want to write off Mississippi as an rogue state, Colorado attempted to pass similar legislation in 2008, which thankfully failed. In fact, Personhood USA is based in Colorado and is the backer for the Mississippi bill. Additional states who are considering personhood laws to circumvent the 1973 Roe versus Wade ruling that confirmed constitutionality for a woman to have an abortion prior to the fetus’s ability to live outside the womb include; Arkansas, Montana, Nevada, and Oklahoma.
From this vantage point there is no end-in-sight for the pitch back to the dark ages for women in the United States. I can almost see the black hole from here.
On a more personal note, I expect my book, Unraveling U.S. Health Care to be available within the first quarter of 2012 and yes, it is OK to say FINALLY. Anyway, thanks for reading and I hope you continue to review and comment on my musings.

State by State Analysis of Patient Rights under 2010 Reforms

State Reactions to 2010 Health Care Reforms
A virtual firestorm has ensued with state reactions to some of the federal government mandates under the health care reforms of 2010, from the Patient Protection and Affordable Care Act, the Public Health Services Act, and the Affordable Health Care Act for America. This article reviews two of these bones of contention, including the consumer protection aspects, which impact the Office of Insurance Commissioners and the reproductive rights provisions.
Consumer Protections under Federal Mandates
The federal government has awarded thirty million dollars in grants to the states to shore up their consumer protection services for health insurance policy holders. Since the insurance commissioners of each state are already charged with this duty, are staffed for it, and are funded by a tax on the insurance premiums for each insurer, I struggle with the necessity of this award. The insurance commissioner’s office for each state are very well funded and provide general revenue to each state well beyond their budget requirements. If those states aren’t able to staff appropriately for consumer protections, they should take this up with their state legislatures.
Upon reviewing the mandated consumer protections, they appear to reinforce existing protections in many states, but perhaps the standardization of the process is a good thing overall. Here are the new rules for an insured’s right to appeal a health insurer’s claim decision:
•Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage
•Gives consumers detailed information about the grounds for the denial of claims or coverage
•Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process
•Ensures a full and fair review of the denial
•Provides consumers with an expedited appeals process in urgent cases
These provisions are already spelled out in the Summary Plan Description which employers are required to distribute to medical plan participants as a federal reporting requirement under ERISA health and welfare plans. The new provisions codify what 44 states already have in operation for the outside appeal process. Still, the thirty million dollars to encourage compliance seems like overkill for the six states who are not already meeting these recommended standards, which were created by the National Association of Insurance Commissioners. Basically the new rules specify that the patient has a right to an independent review of a rejected claim. According to the Kaiser Foundation’s report on external reviews of insurance claims, the insured won 44% of the time on appeal. Certainly this is enough of an incentive for many patients to pursue a claim review, but one has to wonder, if it is a life saving treatment, the appeals process could still exhaust the patient’s treatment window for optimal efficacy.

Reproductive Rights under Federal Health Care Reforms
I reviewed legislation for all fifty states as of June 2010 and 86% of them had bills that were introduced to modify their compliance with the federal insurance exchanges and other mandates, to be rolled out in 2014. Basically here is what the fuss is about; the federal standards state that Medicaid and the insurance exchange plans will cover reproductive procedures. Of course this includes abortion and birth control. Since the Hyde Amendment restricts any federal money from paying for abortion, this means the insurance exchanges and Medicaid plans could include abortion coverage but the states or private employers would pay for it. This has raised the hackles of a lot of people, who do not want to be told what to do when they are going to pay the tab. According to a 2003 survey on contraceptive care provided by insurance programs, 87% of private employers offered coverage for abortion services, which covered approximately 46% of the U.S. population. Since the majority of private employer medical plans already cover abortion and birth control procedures for their female workers, this standard is not new. What is new is the government’s attempt to offer the same reproductive rights to low income women through Medicaid and the subsidies for eligible employers. Many of the states are objecting to the federal requirement that they must offer poor women the opportunity to receive birth control treatment. Why don’t you just keep them barefoot and pregnant? Here are my winners and losers on the reproductive rights bills:
Most female friendly regarding reproductive autonomy
Current Laws
Colorado Law 1021 requires insurers to cover contraceptives if they provide maternity coverage. Wisconsin SA458 improves sex education for youth.
Under Consideration
Illinois- Senate Bill 2482 requires insurance companies who provide prescription drug coverage to include coverage for contraceptives. House Bill 6205 codifies the right to abortion even if Roe-v-Wade is overturned. Bill 6205 also assures the right of Medicaid women to receive contraceptives and abortion as needed. House Bill 6842 blocks some access to reproductive health care under federal health reform stipulations.
Let’s give a shout out to South Dakota for proposing insurance companies cover contraceptives, but also for expanding Medicaid for pregnancy related services. Other states who seek to expand Medicaid for low income women are Alaska and Illinois.
The following states have bills stipulating improvements in sex education, emergency contraceptives upon request (morning after pill), and insurance reimbursement for contraceptives: Pennsylvania, New York, Missouri, Minnesota, California, and Hawaii.
Most paternalistic states regarding female reproductive autonomy
Current Law
Providers Can Decline to Provide Contraceptive Services
The following states have enacted laws which allow health care providers (pharmacists or clinicians) to decline to provide birth control services: Idaho S1353 enacted 3/29/2010 and Oklahoma S1891 signed 4/2/2010.
No Abortions under Private Insurance Plans Either
Under current law, the following states do not allow private insurance funding for abortion services; Kentucky, Missouri, Oklahoma, Idaho, and North Dakota. If you are unfortunate enough to live in North Dakota, now is a good time to consider moving over to the healthier and wealthier Minnesota neighbor, though I must confess I am a former Minnesotan.
No Abortions in Health Insurance Exchanges
States which have enacted laws that restrict abortion and other contraceptive services under state health insurance exchanges include Arizona and Mississippi.
Arizona- S1305 enacted 4/24/2010, prohibits insurance companies participating in the insurance exchanges from offering abortion and S1001 signed 4/1/2010, blocks portions of the federal health care reforms. If that isn’t charming enough, S1305 also prohibits insurance companies who cover state employees from offering abortion coverage.
States Seeking to Limit Birth Control specifically for Low Income Women
Virginia H30 passed 5/17/2010 limiting access to abortion for Medicaid eligible women and
Colorado L1311 prohibits the payment of abortion for Medicaid participants.
Pending Bills Restricting Reproductive Rights
North Carolina currently has a law that allows insurance companies to refuse contraceptive coverage, N.C. 1068 and also restricts access to contraceptives in school health services (let's keep those teen pregnancies coming). The coupe de tat’ Bill 890 makes an unborn child a crime victim separate and apart from the mother, legalizing the fetus status as an individual. North Carolina also introduced a bill on 3/31/2010 requiring all pregnant women to get an ultrasound, regardless of efficacy, to submit to a state lecture on fetal development, and to wait 24 hours before termination. Also a bill was introduced on 4/13/09 to prohibit state employees and teachers from having an abortion paid for by state medical plans. I wonder if the school boards can still fire teachers who become pregnant out of wedlock as well. Double winner here, ladies, cross your legs in NC. Bill 1157 would restrict funding for low income women on Medicaid, by not covering birth control services. A bill introduced on 6/17/2010 would block federal health care standards for women. Finally, Bill 431 would require parental consent in writing before getting an abortion. Let’s see, your parents may have a different religion, different sexual orientation, and you may not even be living with them, but you need their permission? How does this work for foster kids and run-a-ways?
Additional States that seek to limit access to sex education, contraceptives, fair access to birth control for low income women (Medicaid), and to criminalize abortion are:
Alabama, Louisiana, Virginia, Colorado, Nevada, New Mexico.
Does this really matter when the 1977 Hyde Amendment has continually been ratified and every federal budget limits payment for abortion procedures except in the case of rape, incest, or a life threatening situation? The tan-your-Hyde amendment has also been broadened to include no federal reimbursement for abortion for federal employees, women in the military, or for Indian Health Services. The latter is a real confounder since American Indian Tribes are considered sovereign nations, yet are conscripted to obtain health care from the occupying nation with opposing values. The 2010 reproductive rights provisions matter because the states can choose different provisions for abortion financing and service availability through the insurance exchanges and Medicaid programs. There is also specific language to protect clinicians who do not want to provide abortions, but no language protecting those who do. This is another example of unequal rights in the land of the not-so-free. The most onerous task is the mandate to attach a separate premium for abortion costs and to bill it as an addendum to the exchange plans. This seems like a lot of work for the estimated $1 additional cost per eligible woman, but that may be another way for the federal government to discourage abortions. What is next, wearing the letter A on our blouses? The shame attached to a common birth control method and often medically necessary procedure wastes a lot of resources that could be better spent on improving primary care across the board. For example, building a robust sex education program into the school system and providing contraceptive options to the sexually active population.
There will be other issues the states will argue about for health care reform implementations, but I thought we would start off with the most litigious and now the healthpolicymaven is signing off with condom in hand.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.