aea gender final

THE URBAN INSTITUTE

Sharon K. Long University of Minnesota

Karen Stockley Urban Institute

Shanna Shulman Blue Cross Blue Shield of Massachusetts Foundation

American Economic Association Annual MeetingsSession: Gender Gaps in Families, Health Care, and IndustryJanuary 8, 2011

Have Gender Gaps in Insurance Coverage and Access to Care Narrowed Under Health Reform?Findings from Massachusetts

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Background

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Gender Differences in Health Care• Women have greater health care needs than men,

partially driven by: Reproductive health needs among younger women

Higher incidence of chronic conditions for older women

• Women use care more than men Greater health care needs

Higher levels of insurance coverage

• Women face higher medical cost burdens More likely to forgo needed care due to cost

Spend greater share of income on medical care

Sources: James et al. 2009; Rustgi, Doty, and Collins. 2010


Massachusetts Health Reform• Legislation passed in April 2006

• Major goals: Extend comprehensive insurance coverage to all residents Improve access, affordability, quality of health care

• Many parts, including: Medicaid (MassHealth) expansions New income-related subsidies to purchase private coverage

(CommCare) New purchasing arrangement to purchase private coverage

(CommChoice) New entity to regulate and facilitate the purchase of private

coverage (the Connector) Insurance market reforms Requirements for employers Individual mandate

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Research Question• How did gender differences in insurance coverage,

access, use, and affordability of health care change under health reform in Massachusetts? Examine changes in gender gaps in insurance coverage Examine changes in gender gaps in access, use, and

affordability associated with the coverage expansions Expect these gaps to narrow as coverage levels become

more equalized between the sexes

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Data• Massachusetts Health Reform Survey

Pre-reform survey--fall 2006 Post-reform surveys--fall 2007, 2008 and 2009 Stratified random samples Telephone interviews with samples of adults 18 to 64

Oversamples of lower-income and uninsured adults Questions on insurance coverage; access, use, and

affordability of care; support for health reform Sample sizes 3000+ in each year

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Analytic Framework• Compare gender differences in outcomes for cross-

sectional samples of men and women before and after health reform Estimate multivariate regression models of gender

differences before and after reform Controlling for demographic, health and disability,

socioeconomic characteristics, region of state Models of gender differences pre and post-reform

estimated within each year (2006 or 2009) Estimate difference-in-difference models comparing

changes for men and women over the study period Data from 2006-2009 Testing whether significant change in gender differences

under health reform

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Analytic Framework• Changes in gender differences between fall 2006 and

2009 attributed to state’s reform efforts Aggregate impact of health reform on gender disparities

• Assumption: other factors not changing differentially for men and women over the study period Violation could bias interpretation (e.g. if recession

affected men or women more severely)

• Will also provide insight into the benefits of insurance coverage for men and women More speculative findings

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Estimation Approach• Estimate separate models by age group

All non-elderly adults (ages 18-64) Younger adults (ages 18-45) Older adults (ages 46-64)

• Linear probability models, controlling for complex survey design

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Gender Differences Prior to Health Reform

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Women

Insurance coverage Any insurance coverage 91.1 7.8 *** 11.5 *** 2.5 *

ESI coverage 68.0 5.4 *** 5.9 ** 5.4 **Public or other coverage 23.1 2.4 5.6 ** -2.9

Health care access and use in past 12 months Has a usual source of care (excluding the ED) 90.0 5.4 *** 8.3 *** 1.4Any doctor visit 84.7 6.1 *** 7.2 ** 5.0 *Any specialist visit 56.4 10.4 *** 11.3 *** 9.0 **Any dental care visit 72.0 9.1 *** 8.8 *** 8.2 ***Took any prescription drugs 62.0 10.2 *** 14.1 *** 5.7 *Did not get needed care for any reason 27.4 3.5 2.0 4.9Health care costs in past 12 months Had problems paying medical bills 22.3 2.8 0.4 6.5 **Did not get needed care because of costs 17.9 1.7 1.3 2.9

Women-Men Difference for Ages 46 to 64


Regression-adjusted Gender Differences Prior to Health Reform, Fall 2006

* (**) (***) Women-men difference significantly different from zero at the .10 (.05) (.01) level, two-tailed test.

Difference from Men

Ages 18-64

Source: 2006 Massachusetts Health Reform Survey (N=2,925 for adults 18-64; N=1,476 for adults 18 to 45; N=1,445 for adults 46 to 64)

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Changes for Men and Women Under Health Reform

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2006

Insurance coverage Any insurance coverage 91.4 5.7 *** 6.4 *** 4.9 ***

ESI coverage 67.1 1.6 2.7 0.5Public or other coverage 24.3 4.1 ** 3.7 4.5 ***

Health care access and use in past 12 months Has a usual source of care (excluding the ED) 90.3 2.5 ** 2.5 2.6 *Any doctor visit 84.8 5.8 *** 9.6 *** 1.1Any specialist visit 56.6 3.4 4.7 2.3Any dental care visit 72.7 6.4 *** 8.6 *** 2.8Took any prescription drugs 61.8 2.3 1.7 3.4Did not get needed care for any reason 26.9 -5.7 *** -5.9 * -5.5 **Health care costs in past 12 months Had problems paying medical bills 20.9 1.3 2.7 -0.9Did not get needed care because of costs 17.2 -3.7 ** -3.7 -3.4 *

* (**) (***) Change is significantly different from zero at the .10 (.05) (.01) level, two-tailed test.

Regression-adjusted Estimates of Changes for Women Under Health Reform, Fall 2006-Fall 2009Ages 18-64 2006-2009

Change for Ages 18 to 45

2006-2009 Change for

Ages 46 to 652006-2009

Change

Source: 2006-2009 Massachusetts Health Reform Surveys (N=7,444 for women 18 to 64; 3,375 for women 18 to 45; 4,049 for women 46 to 64)


2006


ESI coverage 64.1 3.8 ** 4.4 * 1.9Public or other coverage 19.1 6.2 *** 9.6 *** 2.8

Health care access and use in past 12 months Has a usual source of care (excluding the ED) 83.7 3.2 5.5 * -0.1Any doctor visit 76.2 5.3 ** 5.2 5.1 *Any specialist visit 44.6 0.9 -1.2 4.1Any dental care visit 64.2 5.5 ** 6.1 ** 3.8Took any prescription drugs 49.0 3.0 2.1 4.9 *Did not get needed care for any reason 22.8 -5.1 ** -8.3 *** 0.2Health care costs in past 12 months Had problems paying medical bills 17.3 -1.6 -2.4 -0.4Did not get needed care because of costs 15.2 -5.5 *** -8.5 *** -0.8

* (**) (***) Change is significantly different from zero at the .10 (.05) (.01) level, two-tailed test.

Regression-adjusted Estimates of Changes for Men Under Health Reform, Fall 2006-Fall 2009Ages 18-64 2006-2009

Change for Ages 18 to 45

2006-2009 Change for

Ages 46 to 652006-2009

Change

Source: 2006-2009 Massachusetts Health Reform Surveys (N=5,265 for men 18 to 64; 2,512 for men 18 to 45; 2,741 for men 46 to 64)

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Gender Differences After Health Reform

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Women


ESI coverage 68.7 3.2 2.9 5.1 ***Public or other coverage 28.4 0.5 1.6 -2.8

Health care access and use in past 12 months Has a usual source of care (excluding the ED) 92.8 5.6 *** 6.3 *** 4.9 ***Any doctor visit 90.7 8.0 *** 13.2 *** 0.5Any specialist visit 60.1 14.4 *** 19.6 *** 7.2 *Any dental care visit 79.1 9.2 *** 9.9 *** 8.1 ***Took any prescription drugs 64.1 10.4 *** 17.9 *** -0.1Did not get needed care for any reason 21.2 1.3 4.2 * -2.3Health care costs in past 12 months Had problems paying medical bills 22.2 4.4 ** 5.3 ** 3.4Did not get needed care because of costs 13.6 2.3 ** 5.8 *** -1.4

Bold indicates the women-men difference in fall 2009 is significantly different from the women-men difference in fall 2006 at at least the .10 level, two-tailed test.

* (**) (***) Women-men difference significantly different from zero at the .10 (.05) (.01) level, two-tailed test.

Regression-adjusted Gender Differences After Health Reform, Fall 2009Ages 18-64

Difference from Men



Source: 2009 MHRS (N=3,041 for 18-64; N=1,297 for 18-45; N=1,735 for 46-64) for estimates of 2009 gender differences; 2006-2009 MHRS (N=13,150) for estimates of changes in gender differences over time.

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Conclusions• Men and women both gained under health reform

Coverage expansions associated with gains in access, use, and affordability for both genders

• Narrowing of gender gap in insurance coverage, particularly for younger adults

• Inconsistent financial effect of coverage gains for women and men In 2009 women had higher levels of coverage but were

more likely to report unmet need and problems affording care

Suggests that insurance provides better financial protection for men than women

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aea gender final

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