Carole Roan Gresenz

Relations of income inequality and family income to chronic medical conditions and mental health disorders: national survey.

Abstract Objectives: To analyse the relation between geographical inequalities in income and the prevalence of common chronic medical conditions and mental health disorders, and to compare it with the relation between family income and these health problems. Design: Nationally representative household telephone survey conducted in 1997-8. Setting: 60 metropolitan areas or economic areas of the United States. Participants: 9585 adults who participated in the community tracking study. Main outcome measures: Self report of 17 common chronic medical conditions; current depressive disorder or anxiety disorder assessed by clinical screeners. Results: A strong continuous association was seen between health and education or family income. No relation was found between income inequality and the prevalence of chronic medical problems or depressive disorders and anxiety disorders, either across the whole population or among poorer people. Only self reported overall health, the measure used in previous studies, was significantly correlated with inequality at the population level, but this correlation disappeared after adjustment for individual characteristics. Conclusions: This study provides no evidence for the hypothesis that income inequality is a major risk factor for common disorders of physical or mental health. What is already known on this topic Several studies have found a relation between income inequality and self reported health or mortality What this study adds There is a strong social gradient in health, as measured by the prevalence of chronic medical conditions and specific mental health disorders, by income or education No such association is seen between income inequality and health

Plasma 24-metabolite Panel Predicts Preclinical Transition to Clinical Stages of Alzheimer’s Disease

We recently documented plasma lipid dysregulation in preclinical late-onset Alzheimer’s disease (LOAD). A 10 plasma lipid panel, predicted phenoconversion and provided 90% sensitivity and 85% specificity in differentiating an at-risk group from those that would remain cognitively intact. Despite these encouraging results, low positive predictive values limit the clinical usefulness of this panel as a screening tool in subjects aged 70–80 years or younger. In this report, we re-examine our metabolomic data, analyzing baseline plasma specimens from our group of phenoconverters (n = 28) and a matched set of cognitively normal subjects (n = 73), and discover and internally validate a panel of 24 plasma metabolites. The new panel provides a classifier with receiver operating characteristic area under the curve for the discovery and internal validation cohort of 1.0 and 0.995 (95% confidence intervals of 1.0–1.0, and 0.981–1.0), respectively. Twenty-two of the 24 metabolites were significantly dysregulated lipids. While positive and negative predictive values were improved compared to our 10-lipid panel, low positive predictive values provide a reality check on the utility of such biomarkers in this age group (or younger). Through inclusion of additional significantly dysregulated analyte species, our new biomarker panel provides greater accuracy in our cohort but remains limited by predictive power. Unfortunately, the novel metabolite panel alone may not provide improvement in counseling and management of at-risk individuals but may further improve selection of subjects for LOAD secondary prevention trials. We expect that external validation will remain challenging due to our stringent study design, especially compared with more diverse subject cohorts. We do anticipate, however, external validation of reduced plasma lipid species as a predictor of phenoconversion to either prodromal or manifest LOAD.

Understanding Disparities In Health Care Access—And Reducing Them—Through A Focus On Public Health

Attempts to explain disparities in access to health care faced by racial and ethnic minorities and other underserved populations often focus on individual-level factors such as demographics, personal health beliefs, and health insurance status. This article proposes an examination of these disparities-and an effort to redress them-through the lens of public health. Public health agencies can link people to needed services such as immunizations, testing, and treatment; ensure the availability of health care; ensure the competency of the public health and personal health care workforce; and evaluate the effectiveness, accessibility, and quality of personal and population-based services. Approaching disparities through a public health framework can provide the foundation for developing more robust evidence to inform additional policies for improving access and reducing disparities.

Dimensions of the Local Health Care Environment and Use of Care by Uninsured Children in Rural and Urban Areas

OBJECTIVE. Despite concerted policy efforts, a sizeable percentage of children lack health insurance coverage. This article examines the impact of the health care safety net and health care market structure on the use of health care by uninsured children. METHODS. We used the Medical Expenditure Panel Survey linked with data from multiple sources to analyze health care utilization among uninsured children. We ran analyses separately for children who lived in rural and urban areas and assessed the effects on utilization of the availability of safety net providers, safety net funding, supply of primary care physicians, health maintenance organization penetration, and the percentage of people who are uninsured, controlling for other factors that influence use. RESULTS. Fewer than half of uninsured children had office-based visits to health care providers during the year, 8% of rural and 10% of urban children visited the emergency department at least once, and just over half of children had medical expenditures or charges during the year. Among uninsured children in rural areas, living closer to a safety net provider and living in an area with a higher supply of primary care physicians were positively associated with higher use and medical expenditures. In urban areas, the supply of primary care physicians and the level of safety net funding were positively associated with uninsured childrens medical expenditures, whereas the percentage of the population that was uninsured was negatively associated with use of the emergency department. CONCLUSIONS. Uninsured children had low levels of utilization over a range of different health care provider types and settings. The availability of safety net providers in the local area and the safety nets capacity to serve the uninsured influence access to care among children. Possible measures for ensuring access to health care among uninsured children include increasing the density of safety net providers in rural areas, enhancing funding for the safety net, and policies to increase primary care physician supply.

Health Care Experiences of Hispanics in New and Traditional U.S. Destinations

Over the past 15 years, striking new settlement patterns have emerged that have brought about unprecedented geographic dispersion in the population of approximately 45 million Hispanics in the United States. In this study, the authors compare the health care experiences of working age U.S.-born Mexican Americans and Mexican immigrants living in new and traditional Hispanic destinations. They use a geocoded version of the Medical Expenditure Panel Survey Household Component linked to contextual data from secondary sources. They characterize destinations as new or traditional using information on the percentage of the population that was Hispanic in 1990 and the growth in percent Hispanic between 1990 and 2000. The authors find that, compared with living in destinations with a well-established Hispanic presence, U.S.-born Mexican Americans living in new destinations have less favorable health care outcomes, including a greater probability of having an unmet need for or delay in receiving medical care and reduced satisfaction with care.

Disputes over coverage of emergency department services: a study of two health maintenance organizations.

STUDY OBJECTIVE We describe the characteristics and outcomes of enrollee-health plan disputes over insurance coverage for emergency department (ED) services at 2 large health maintenance organizations (HMOs) that apply the prudent layperson standard. METHODS We abstracted information from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nations largest HMOs (hereafter referred to as Plan 1 and Plan 2). We describe appeals involving ED services in terms of the timing of visits, patient age, costs of services, primary reason the patient sought care, and appeal outcome. RESULTS Disputes over ED services accounted for approximately one half (52%) of postservice appeals at Plan 1 and one third (34%) at Plan 2. Nearly one half (46%) of ED appeals involved weekend, nighttime, or holiday visits to the ED; 22% were childrens visits. The average cost of services in dispute was US

Spillover effects of community uninsurance on working-age adults and seniors: an instrumental variables analysis.

1,107. The most common general reasons for the ED visits in dispute were symptoms of illness (64%), injuries (22%), and services related to disease (8%). The most common presenting symptoms were abdominal pain, cramps, or spasms (7.6%); earaches or ear infections (3.4%); and lacerations/cuts (2.9%). Enrollees won more than 90% of appeals. CONCLUSION The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard.

Who Leaves Managed Behavioral Health Care

Background:Previous research suggests, but does not definitively establish, that a high level of uninsurance in a community may negatively affect access to and quality of health care for insured persons. Objective:To assess the effect of the level of uninsurance in a community on access to and satisfaction with care—an important dimension of quality—among insured persons. Research Design:The 1996 to 2006 Medical Expenditure Panel Survey Household Component data linked to data from the Current Population Survey, Area Resource File, and the InterStudy Competitive Edge. Analyses include 86,928 insured adult respondents living in approximately 200 large metropolitan areas. Main Outcome Measures:Measures of whether an individual had a usual source of care, had any delay/difficulty obtaining needed care, used office-based services, used prescription drug services, and used any medical services, and measures of satisfaction with care. Results:Among privately insured adults, a higher community uninsurance rate resulted in a lower probability of having a usual source of care, having an office-based visit, having any medical expenditures, and reporting being satisfied with the quality of care provided by the usual source of care. A higher community uninsurance rate also led to a higher probability of reporting difficulty obtaining needed care. Among Medicare enrollees, a higher community uninsurance rate resulted in lower reported satisfaction with care and higher probability of experiencing difficulty or delay in getting needed care. Conclusions:Our results suggest substantial spillover effects of the community uninsurance rate on access to and satisfaction with health care among insured working-age adults and seniors. Consequently, new efforts to address the problem of the uninsured may bring significant benefits to persons who already have insurance.

Income Eligibility Thresholds, Premium Contributions, and Children's Coverage Outcomes: A Study of CHIP Expansions

The growth of managed care and the possibility of biased enrollment and disenrollment rates have raised concerns about cost shifting. This article analyzes the duration of continuous enrollment in a managed behavioral health organization among members with and without behavioral health care utilization and among members with different mental health conditions. Eleven large employers with more than 250,000 members who are enrolled in managed behavioral health plans are studied. Compared to managed care 10 years ago, the rate of disenrollment among patients with depression appears to have dropped. Moreover, there appear few differences in disenrollment among users and nonusers of behavioral health services, except for employees for whom coverage is linked to job performance. However, patients with substance abuse problems or severe types of disorders are significantly more likely to disenroll than patients with less severe problems.

Mental Health and Employment Transitions

OBJECTIVE To understand the effects of Childrens Health Insurance Program (CHIP) income eligibility thresholds and premium contribution requirements on health insurance coverage outcomes among children. DATA SOURCES 2002-2009 Annual Social and Economic Supplements of the Current Population Survey linked to data from multiple secondary data sources. STUDY DESIGN We use a selection correction model to simultaneously estimate program eligibility and coverage outcomes conditional upon eligibility. We simulate the effects of three premium schedules representing a range of generosity levels and the effects of income eligibility thresholds ranging from 200 to 400 percent of the federal poverty line. PRINCIPAL FINDINGS Premium contribution requirements decrease enrollment in public coverage and increase enrollment in private coverage, with larger effects for greater contribution levels. Our simulation results suggest minimal changes in coverage outcomes from eligibility expansions to higher income families under premium schedules that require more than a modest contribution (medium or high schedules). CONCLUSIONS Our simulation results are useful counterpoints to previous research that has estimated the average effect of program expansions as they were implemented without disentangling the effects of premiums or other program features. The sensitivity to premiums observed suggests that although contribution requirements may be effective in reducing crowd-out, they also have the potential, depending on the level of contribution required, to nullify the effects of CHIP expansions entirely. The persistence of uninsurance among children under the range of simulated scenarios points to the importance of Affordable Care Act provisions designed to make the process of obtaining coverage transparent and navigable.