Determinants of private health insurance coverage among Mexican American men 2010–2013

Abstract

Background: Private health insurance (PHI) represents the largest source of insurance for Americans. Hispanic Americans have one of the lowest rates of PHI coverage. The largest group in the US Hispanic population are Mexican Americans; they account for about two in every three Hispanics. One in every three Mexican Americans aged 64 years and under did not have health insurance coverage. Mexican Americans have the most unfavorable health insurance coverage of any population group in the nation.

Objectives: The objective is to determine the factors associated with the gap in PHI coverage between Mexican American and non-Hispanic American men.

Methods: This study used the National Health Interview Surveys (2010–2013) as the sample. A non-linear Oaxaca-Blinder decomposition was run, estimating the explained and unexplained gap in PHI coverage between the groups. Several robustness tests of the model were also included.

Results: This study estimates that 44.4% of employed Mexican American men are covered by PHI compared to 79.5% of non-Hispanic American men. Nearly 60% of employed Mexican American men were found to be foreign born, 35% have an educational attainment less than a high school degree, and 40% are likely to have language barriers. Decomposition results show that income, low educational attainment, being foreign-born, and language barriers diminished the probability of private health insurance coverage for Mexican Americans, and that 10% of the gap is unexplained.

Conclusions: Most of the difference in the PHI rate between Mexican American men and non-Hispanic men is explained by observable differences in group characteristics: education, language, and immigration status. About 10% of the difference can be attributed to discrimination under the traditional interpretation of an Oaxaca-Blinder decomposition. The PHI rate gap is large and persistent for Mexican American men.     

Determinants of specialist physician ambulatory visits: a neurology example

Background: Economic theory argues that specialization in medicine improves efficiency. Current literature suggests that access to and utilization of specialist care vary widely based on many determinants. Thus, understanding the determinants of specialist physician ambulatory care utilization is integral to healthcare policy.

Objectives: The objective is to investigate the individual and community determinants of specialist ambulatory care utilization—specifically neurologists. The aim was to find predictors of specialist utilization and to identify the particular determinants that can be modified by regulatory or legislative action.

Methods: A large claims database, Truven Health Analytics? Marketscan data, was used from 2007–2010 as the sample. These data are supplemented with data from the American Academy of Neurology (for geographic distribution of neurologists) and the US Census American FactFinder (for community demographic factors). Multivariate regression analysis was run to test the hypotheses. Several robustness tests of our models were included.

Results: Most importantly, neurologists per capita has a meaningful impact on utilization. Additionally, the difference in neurologist usage by neurological condition is an important factor. It was also found that union status, age, comorbidities, and diagnosis are significant individual level determinants, and that the percentage of Hispanic residents and median income are significant community level determinants.

Conclusions: There are two predictors believed to be the most important. The first is the unique neurologists per 1,000 capita variable, which shows a small increase in the number of neurologists would be correlated with a small increase in the probability of seeing a neurologist. We suggest that this is within policymakers’ control, and policymakers should consider this action in the face of the predicted shortage. The second is what appears to be possible sorting by neurologists of patients based on diagnosis – the large difference in the fraction of patients seeing a neurologist by disease.     

Cost-effectiveness of Access to Critical Cerebral Emergency Support Services (ACCESS): a neuro-emergent telemedicine consultation program

Aims: Access to Critical Cerebral Emergency Support Services (ACCESS) was developed as a low-cost solution to providing neuro-emergent consultations to rural hospitals in New Mexico that do not offer comprehensive stroke care. ACCESS is a two-way audio-visual program linking remote emergency department physicians and their patients to stroke specialists. ACCESS also has an education component in which hospitals receive training from stroke specialists on the triage and treatment of patients. This study assessed the clinical and economic outcomes of the ACCESS program in providing services to rural New Mexico from a healthcare payer perspective.

Methods: A decision tree model was constructed using findings from the ACCESS program and existing literature, the likelihood that a patient will receive a tissue plasminogen activator (tPA), cost of care, and resulting quality adjusted life years (QALYs). Data from the ACCESS program includes emergency room patients in rural New Mexico from May 2015 to August 2016. Outcomes and costs have been estimated for patients who were taken to a hospital providing neurological telecare and patients who were not.

Results: The use of ACCESS decreased neuro-emergent stroke patient transfers from rural hospitals to urban settings from 85% to 5% (no tPA) and 90% to 23% (tPA), while stroke specialist reading of patient CT/MRI imaging within 3?h of onset of stroke symptoms increased from 2% to 22%. Results indicate that use of ACCESS has the potential to save $4,241 ($3,952–$4,438) per patient and increase QALYs by 0.20 (0.14–0.22). This increase in QALYs equates to ～73 more days of life at full health. The cost savings and QALYs are expected to increase when moving from a 90-day model to a lifetime model.

Conclusion: The analysis demonstrates potential savings and improved quality-of-life associated with the use of ACCESS for patients presenting to rural hospitals with acute ischemic stroke (AIS).     

Examining the effect of IMF conditionality on natural resource policy

Can International Monetary Fund (IMF) lending improve natural resource governance in borrowing countries? While most IMF agreements mandate policy reforms in exchange for financial support, compliance with these reforms is mixed at best. The natural resource sector should be no exception. After all, resource windfalls enable short-term increases in discretionary spending, and office-seeking politicians are often unwilling to forgo this discretion by reforming the oil, gas, or mining sector. I investigate how and when borrowers go against their political interests and establish natural resource funds—a tool often promoted by the IMF—in the wake of a loan agreement. Using text analysis, statistical models, and qualitative evidence from natural resource policy and IMF conditionality for 74 countries between 1980 and 2019, I show that borrowers under an IMF agreement are more likely to create or regulate a resource fund, particularly if the agreement includes binding conditions that highlight the salience of natural resource reforms. This study contributes to extant research by proposing a new method to extract information from IMF conditions, by introducing a novel dataset on country-level natural resource policy, and by identifying under what circumstances international reform efforts can help combat the resource curse.