The impact of health insurance coverage on the lives of low-income adults: A study of the effectiveness of the Vermont Health Access Plan

Context. There is considerable research on the problems facing low-income, uninsured adults. Less is known about the extent that the uninsured use subsidized insurance when provided, or the impact of these benefits on their health.; Objectives. Understand the benefits and costs of insuring low-income Vermonters. Examine benefit use and changes in health access, utilization, health status and satisfaction with care. Test theoretical models of selection bias, access, use, outcomes and satisfaction. Make recommendations for improving program design, effectiveness and future research.; Research design. A cross-sectional analysis compares enrollees with eligible non-enrollees. A longitudinal study comparing uninsured health outcomes one year prior to enrollment and one year later measures program impact. Bi-variate and multiple regression compare results from phone interviews at enrollment and one year later.; Setting. Vermont; a national leader in incremental health reform, with 14 rural and semi-urban counties, a population of 580,000, and an uninsured rate of 7% in 1997.; Subjects. 406 low-income uninsured adults randomly selected from Vermont Health Access Plan (VHAP) administrative records. Of these, 253 (62%) responded to both interviews. 74% of those with phones responded to both interviews.; Results. VHAP improves access and promotes timely treatment in appropriate settings. Two thirds of eligible Vermonters enroll. Enrollees are sicker than non-enrollees, and male enrollees are less healthier than females. Four in ten have a health problem and half have been uninsured for more than five years. A third have coverage at work, but opt for public insurance. While uninsured, half delay getting care they need and a third go without it. While uninsured, four in five visited a physician and one in five was hospitalized. After a year hospital use declined by 42%, ER use dropped 25%, and dental use increased by 10%. Doctor's visits increased slightly and mental health visits increased by 97%. Insurance improved overall satisfaction and health status; the odds of reporting a health problem declined by 44%. Program impact varies by age, gender, community and health status. A third lose eligibility within a year due to increased earnings. VHAP costs are estimated to be lower than the costs of treating the uninsured.