Citation URL: http://www.urban.org/LenNichols

This Health Services Research article by Genevieve Kenney, John Holahan, and Len Nichols investigates the extent to which federal surveys that are regularly used to provide information on health insurance coverage and access to care contain the needed data elements to accurately assess alternative policy options to address the problem of uninsurance. The authors conclude that existing surveys have major data gaps and suggest possible solutions. For example, the content of the Current Population Survey could be modified to deal with current shortcomings in the measurement of insurance coverage. (Health Services Research 41(3): 918-945, 2006.)

A specific focus for state regulations of the small group insurance market was to increase offers and stabilize premiums for firms with high-risk workers. We examine the effect of reforms implemented from 1993 through 1996 on the likelihood of employer sponsored insurance coverage. We find that packages of reforms that included both guaranteed issue of some products and some form of rate variance restriction had significant positive effects on ESI coverage for high-risk compared with low-risk workers within small firms and a small negative effect on low-risk workers in small compared with large firms. (Davidoff, Amy, Blumberg, Linda and Nichols, Len. 2005. "State Health Insurance Market Reforms and Access to Insurance for High-Risk Employees." Journal of Health Economics 24(4): 725-750.)

After slow growth during much of the 1990's, Medicaid physician fees increased, on average, by 27.4 percent between 1998 and 2003. The greatest growth occurred for primary care fees. States with the lowest relative fees in 1998 increased their fees the most, but almost no states changed their position relative to other states or Medicare. Physicians in states with the lowest Medicaid fees were less willing to accept most or all new Medicaid patients in both 1998 and 2003. However, large fee increases were associated with an increased willingness of primary care physicians to accept new Medicaid patients (Health Affairs Web Exclusive, June 23, 2004.)

The Health Insurance Reform Simulation Model (HIRSM) is designed to simulate the coverage, cost, and tax implications of health insurance coverage expansion proposals and other reforms to the health insurance system. The model uses nationally representative data on employers, workers, and those outside of the labor market. HIRSM simulates the behavioral choices of insurers, employers, and individuals under the current system and under reform, allowing us to predict the coverage consequences of various policies. It can simulate the effects of reforms affecting private insurance markets and public programs. This report details the model in its entirety and presents prototypical results.

This article reports results from using the Health Insurance Reform Simulation Model (HIRSM) to simulate the effects of a proposal for expanding health insurance developed by Holahan, Nichols, and Blumberg. This expansion proposal would subsidize health insurance purchases for low-income individuals and families and simultaneously addresses the issue of inefficient and inequitable risk pooling in current private health insurance markets. The results suggest that roughly half of the uninsured population would obtain coverage under this plan, while preserving the role of employers as a major payer for coverage. Unlike other proposals that would subsidize coverage for the low-income, this plan would also significantly reduce the inefficient risk-pooling in individual and small group markets. (American Economic Association Papers and Proceedings 93(2): 277–82, May 2003.)

We compare three methods that policies seeking to expand health insurance coverage could use to target uninsured people in working families – poverty, hourly wages, and employment in a small firm. We make pair wise comparisons among these, and find that targeting by poverty is most effective and efficient. A poverty-based method is also the most effective way to target those lacking access to employer-sponsored insurance (ESI) and those with low take-up of ESI. When we examine the effectiveness of targeting by family type, we find that marital status and number of workers in the family makes little difference once we control for the presence of children and poverty level. (Health Affairs 2002 July/August; 21(4): 246-254).

Researchers, John Holahan, Len Nichols, and Linda Blumberg outline a new proposal to cover the uninsured that would extend the subsidized coverage that is available under the State Children's Health Insurance Program (S-CHIP) to all lower-income people. This proposal — designed to expand health insurance coverage — was written as a component of a Robert Wood Johnson Foundation-funded project which was directed by The Economic and Social Research Institute (ESRI). Nine other proposals were also written by other authors under the auspices of this project, "Covering America: Real Remedies for the Uninsured." All 10 proposals can be accessed through the ESRI web-site www.esresearch.org.

Recent research has attempted to discern what share of uninsured workers lack coverage due to the absence of an employer sponsored insurance (ESI) offer and what share lack coverage due to a decision to decline an available ESI offer. While most uninsured workers do not have available ESI offers, descriptive evidence clearly indicates that the rate of workers taking up ESI offers has declined since the late 1980s. Central questions in this inquiry are: (1) What is more important in the worker’s decision making— price or health status? (2) Does this relative valuation vary with income? This study uses the National Health Interview Survey (NHIS) and a multivariate analytic framework to answer these questions. Specifically, the study uses premium data and the NHIS’ uniquely detailed information on health status to determine the relative importance of these factors in the worker take-up decision. Overall, the data support the inference that price is more important in the purchase decision than is health status. The exception to this is that high income individuals are not responsive to price in their decision to buy ESI coverage of some type. They were, however, price responsive in their decision to buy a family instead of a single policy, given a decision to buy something. Report to the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2001 December.

This paper uses data from the 1997 National Health Interview Survey to compare workers who decline employers’ offers of health insurance (decliners) with comparison groups of workers who take up offers of employer coverage and those who do not have such offers. Uninsured decliners fare much worse than coverage takers on every mental health measure. While the evidence on physical health measures is somewhat mixed, decliners who are not healthy appear to have greater difficulty obtaining needed services than do workers who take up employer coverage, although decliners tend to have somewhat better access than do the uninsured who are not offered such coverage. (Health Affairs 2001 November/December; 20(6): 180-187).

Most of the uninsured are either workers or family members of workers, and most Americans who are covered get their health insurance through the workplace. These facts motivate our study of two questions: Why do some workers have employer-sponsored health insurance while others do not? What policy initiatives are best suited to the specific conditions of most uninsured workers? We survey the literature on the working uninsured and use 1999 Current Population Survey data to paint a more detailed portrait of the working uninsured that can inform policy discussions.

Return to list of authors