the Department of Family and Community Medicine and the Department of Pediatrics, Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento; and the Department of Family Medicine and Community and Preventive Medicine, Center to Improve Communication in Health Care, University of Rochester School of Medicine and Dentistry, Rochester, NY.
J Am Board Fam Med. 2013 Nov-Dec;26(6):759-67. doi: 10.3122/jabfm.2013.06.130054.
Economists posit 2 mechanisms increasing financial risk to insurers after health insurance gain: ex ante moral hazard (riskier behavior because of reduced personal costs) and ex post moral hazard (increased use of care because of lower care costs). In contrast, the Health Belief Model (HBM), would anticipate no increase in risk behaviors while also predicting increased health care utilization following insurance gain (because of reduced financial barriers to accessing care). Empirical studies examining the association of insurance change with changes in preventive care and health behaviors have been limited and yielded mixed findings. The objective of this study was to examine the association of health insurance change (gain or loss of coverage) with changes in preventive care and health behaviors in a large, nationally representative sample.
We analyzed data from adults ≥18 years old and enrolled for 2 years in the 2000 to 2009 Medical Expenditure Panel Surveys (n = 76,518). Conditional logistic regression analyses modeled year-to-year individual changes in preventive care and health behaviors associated with individual changes in insurance status, adjusting for characteristics varying year to year (income, employment, total health care expenditures, office visits, prescriptions, availability of usual source of care, and health status). Preventive care included adherence to influenza vaccination, colorectal cancer screening, mammography, and Papanicolaou and prostate-specific antigen testing. Health behaviors examined were becoming nonobese, quitting smoking, and adopting consistent use of seatbelts.
Insurance gain (loss) was associated with increases (decreases) in preventive care (adjusted odds ratios [95% confidence intervals]: influenza vaccine, 1.27 [1.04-1.56]; colorectal cancer screening, 1.48 [0.96-2.29]; Papanicolaou testing, 1.56 [1.22-2.00]; mammography, 1.70 [1.21-2.38]; prostate-specific antigen, 1.42 [0.98-2.05]). Insurance change was not associated with significant changes in health behaviors.
Consistent with both economic theory and the HBM, preventive care increased (decreased) after gaining (losing) coverage. In contrast, health behaviors changed little after insurance change, consistent with the HBM but not with the potential for decreased personal health care costs (ex ante moral hazard).
经济学家提出了两种机制，即在获得健康保险后增加保险公司的财务风险：事前道德风险（由于个人成本降低而导致的风险行为）和事后道德风险（由于护理成本降低而导致的护理使用增加）。相比之下，健康信念模型（HBM）预计在获得保险后不会增加风险行为，同时也预测医疗保健利用率会增加（因为获得医疗保健的经济障碍减少）。检查保险变更与预防保健和健康行为变化之间关联的实证研究有限，结果喜忧参半。本研究的目的是在一个大型的全国代表性样本中检查健康保险变更（获得或丧失保险范围）与预防保健和健康行为变化之间的关联。
我们分析了 2000 年至 2009 年医疗支出面板调查中≥18 岁且参加了两年调查的成年人的数据（n=76518）。使用条件逻辑回归分析，针对个体保险状况的变化，对个体每年预防保健和健康行为的变化进行建模，调整了逐年变化的特征（收入、就业、总医疗保健支出、就诊次数、处方、通常来源的医疗保健可用性和健康状况）。预防保健包括遵循流感疫苗接种、结直肠癌筛查、乳房 X 光检查和巴氏涂片及前列腺特异性抗原检查。检查的健康行为包括变瘦、戒烟和始终使用安全带。
获得（丧失）保险与预防保健的增加（减少）有关（调整后的优势比[95%置信区间]：流感疫苗接种，1.27[1.04-1.56]；结直肠癌筛查，1.48[0.96-2.29]；巴氏涂片检查，1.56[1.22-2.00]；乳房 X 光检查，1.70[1.21-2.38]；前列腺特异性抗原检查，1.42[0.98-2.05]）。保险变更与健康行为的显著变化无关。
与经济理论和 HBM 一致，获得（丧失）保险后，预防保健有所增加（减少）。相比之下，保险变更后健康行为变化不大，这与 HBM 一致，但与个人医疗保健成本降低的可能性（事前道德风险）不一致。
