The effects of cost sharing on access to care among childless adults.

Health insurance is an important enabling factor in providing access to physician services and preventive care. Many low-income individuals rely on public insurance programs as an important source of coverage. However, such coverage is generally limited to children, their parents, pregnant women, and the disabled, thus leaving many adults without children ineligible for public coverage regardless of their income. In 2007, 46 percent of childless adults with incomes below the federal poverty level and 37 percent of those between one and two times the federal poverty level were without health insurance coverage (Hoffman et al. 2008). Lack of health insurance results in worse health outcomes, because the uninsured receive less preventive care, are diagnosed at more advanced disease stages, receive less comprehensive care, and have higher mortality rates (Coleman et al. 2002). In recent years, changes in federal policy provided states with more opportunities to expand public insurance coverage to adults. States could expand coverage to adults through 1115 waivers and Health Insurance Flexibility and Accountability (HIFA) waivers (Coughlin et al. 2006). These waivers allowed states to test and evaluate innovative health insurance approaches. Additionally, states can pursue expansions without a federal Medicaid waiver if they bear the full cost of the expansions. Given the flexibility states have in increasing cost sharing through premiums, copayments, and deductibles, a number of states have enacted adult programs with leaner benefit packages, requiring significantly more cost sharing than the state's Medicaid program. Findings from the RAND Health Insurance Experiment show that enrollee cost sharing reduced the use of both highly effective and less effective health services, with generally no adverse effects on health status except those at high risk, particularly among the low income (Newhouse et al. 1993). Cost-sharing requirements could lead to barriers in accessing physician services and preventive health screenings, particularly among low-income individuals, because they have very limited resources to devote to health care. Thus, it is important to examine how cost-sharing requirements impact insurance coverage and access to care among low-income childless adults eligible for public health insurance expansions. In this paper, data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1997 to 2007 is used to analyze the impact of state public health insurance expansions on health insurance status and access to care of low-income childless adults. This study not only examines the impact of insurance expansions on uninsurance rates but goes one step further and examines the impact of these expansions on the receipt of clinically indicated preventive screenings and access to physician services. This paper also provides an analysis of the impact of insurance generosity on access to care by examining the association between cost-sharing levels and access to physician services and preventive screenings. On the eve of health care reform, which will expand Medicaid to individuals up to 133 percent of the federal poverty level, including childless adults, this work provides important insights into the effect of public health insurance expansions on the low-income childless adult population.