Individual Insurance and Access to Care
Keywords: propensity score, sensitivity analysis, bivariate probit, individual insurance
Some proposals to expand insurance coverage in the United States rely in part on the market for non-employment-related private insurance (“individual insurance”). We ask: do people with individual insurance have similar or worse access to care than those with employment-related insurance?
The data are a sample of nonelderly drawn from the nationally representative Medical Expenditure Panel Survey (MEPS), Panels 6 through 10 (2001-2006). We assess multiple measures of access, including having a usual source of care, unmet needs, delays getting care, getting needed care right away, getting routine appointments as soon as desired, and problems seeing specialists. These access measures refer to the prior 12 months, so we compare nonelderly adults with 12 months of individual insurance and those with 12 months of employment-related insurance.
The comparability of the two groups is a critical issue in using observational data. Families in which all workers are self-employed only have individual insurance and have very different attitudes toward risk, so we exclude them from the analysis. The resulting sample has 586 adults with individual insurance and 21,426 with employment-related insurance. We can account for differences in measured health status, chronic conditions (arthritis, diabetes, asthma, ischemic heart disease, stroke, obesity, emphysema, and high blood pressure), income, attitudes, health behaviors, socioeconomic characteristics, and provider availability, but there may be differences in unmeasured characteristics. In bivariate probit models, potential instrumental variables fail overidentification tests, so we compare estimates using propensity scores and estimates from sensitivity analyses using bivariate probit models and conjectured correlations between insurance type and outcomes.
In a preliminary analysis, adults with individual and employment-related insurance report similar, often good, access to physicians. Very few privately insured adults report unmet needs and delays getting care, but those with individual insurance are more likely to report delays getting medical care and unmet needs for dental care. Access to dental care is a bigger problem for those with individual insurance, because those with individual insurance are much less likely to report they have dental coverage.