Research by Author & Topic

Publications by Brenda Spillman on Health and Health Care

Although the prevalence of late-life disability has been declining, how to promote further reductions has been unclear. We developed an analytical framework that compares the effects of different interventions on the prevalence of late-life disability. We considered three potentially high-impact intervention strategies: physical activity programs, depression screening and treatment, and fall prevention. We conclude that in the short run multi-component fall-prevention efforts have the greatest impact. At present, longer-term impacts cannot be assessed based on the current literature and may differ from short-run conclusions, since increases in longevity may temper the effect intervention strategies have on prevalence of late-life disabilities. (Milbank Quarterly 84(3): 493-520, 2006.)

This article attempts to resolve previously published inconsistencies across national surveys in trends in activity limitations among the elderly. The authors prepared estimates from five national surveys from 1982-2001, and investigated sources of the inconsistencies. The panel found consistent declines of 1%-2.5% per year for two commonly used disability measures: difficulty with, and help with daily activities. Mixed evidence was found for the use of help or equipment. The panel found that the period, definition of disability, treatment of the institutionalized population, and age standardizing of results affected results. The implications of the findings for policy, national survey efforts, and further research are discussed. (Freedman, VA, E Crimmins, RF Schoeni, B Spillman, H Aykan, K Land, J Lubitz, K Manton, L Martin, D Shinberg, T Waidmann. 2004. "Resolving Discrepancies in Old-Age Disability Trends Across National Surveys: Report From a Technical Working Group." Demography 41(3):417-441.)

Recent research indicating a downward trend in age-adjusted chronic disability among older Americans has caused some to speculate that the declines will moderate future health costs. This study examines the trend's underlying components using data from the 1984–1999 National Long-Term Care Surveys to better understand the declines and potential implications for acute and long-term care costs. The reductions occurred primarily for activities like financial management and shopping. Assistance with personal care activities associated with greater frailty fell less, and independence with assistive devices rose. Institutional residence was stable. More needs to be known about the extent to which disability declines reflect environmental improvements allowing greater independence at any level of health, rather than improvements in health, before concluding that the declines will mean lower costs. (The Milbank Quarterly 82(1): 157–94, 2004.)

Using data from the 1997 National Survey of America's Families and county-level data on local safety net conditions, the authors find little variation in utilization and access among low-income adults by local safety net conditions, but very large differences by insurance status, after controlling for individual demographic characteristics and health care market characteristics. This suggests that expanding insurance coverage would be a more effective tool for increasing health care use and access among low-income adults than expanding the safety net.

This study explores the properties of an integrated income and disability annuity as an alternative framework for long-term care financing, demonstrating that pooling disability and mortality risks can reduce the need for medical underwriting, and discussing private and public implications. Specifically, a simulation indicates that pooling these competing risks can reduce the costs of both the income annuity and the disability coverage and expand the medically eligible population to 98 percent of 65-year-olds. Combining income and disability protection may be able to expand private markets for long-term care financing beyond what appears possible in the conventional long-term care insurance market, and is only one of multiple models that could be considered for long-term care financing. Public policy should foster innovation in financing mechanisms and avoid the distortion of choices created by exclusive policy focus on a conventional insurance model. (Journal of Aging and Health 15(1): 45–73, 2003.)

The strength or weakness of a state's safety net does not affect the gap between the insured and uninsured in access to and use of health care services. With few exceptions, the gap in access and use was no larger in states with the most vulnerable safety nets than in states with the least vulnerable safety nets. This report classified 13 states on safety net vulnerability and uses the National Survey of America's Families (NSAF) to measure access and utilization of health coverage. Regardless of the safety net's vulnerability, the uninsured in all states do have access to care and do use services, although the levels are well below those of the insured. While the gaps between the uninsured and the insured show little variation among states, low-income populations are better off in states where they are more likely to be insured.

This article examines the implications of the positive correlation of mortality and disability for the benefits of combining an immediate income annuity with long-term care disability coverage at retirement ages. It also investigates the value of such a combined benefit to various subgroups of prospective purchasers and the implications of possible errors and moral hazard in the reporting of disability status and making claims. (The Journal of Risk and Insurance, 2001, Vol. 68, No. 2, 225-254)

The author analyzes states' success in covering their uninsured citizens. Nationwide in 1997, the insurance gap, defined as the share of a state's non-elderly adult residents who would be uninsured in the absence of public insurance coverage, was 21 percent. Of the 13 states studied, the insurance gap ranged from 30.4 percent in Texas to 12.2 percent in Wisconsin. States with limited public insurance programs generally covered the smallest proportion of their insurance gap for all income groups. On average, states with comprehensive programs covered twice the proportion of their insurance gap for low-income adults relative to limited program states. Even in comprehensive program states a substantial proportion of low income adults who lacked other insurance were not reached by public coverage.

[© Health Affairs] Policy attention for the uninsured has focused recently on children, despite the fact that nonelderly adults represent about three-quarters of the uninsured. Nationally, adults are 40 percent more likely than children to be uninsured and less than half as likely to have public coverage. Although their approaches differ greatly, all states cover some adults through their Medicaid programs, partially funded by a 50–77 percent federal match. Using data from the National Survey of America's Families (NSAF), this paper examines how different state approaches affected the number of nonelderly adults who obtained public coverage in 1996.