标题：Stability and Change in Health Insurance Among Older Mexican Americans: Longitudinal Evidence From the Hispanic Established Populations for Epidemiologic Study of the Elderly
摘要：Objectives. This study examined the association between health insurance coverage, medical care use, limitations in activities of daily living, and mortality among older Mexican-origin individuals. Methods. We analyzed longitudinal data from the Hispanic Established Populations for Epidemiologic Study of the Elderly (H-EPESE). Results. The uninsured tend to be younger, female, poor, and foreign born. They report fewer health care visits, are less likely to have a usual source of care, and more often receive care in Mexico. Conversely, those with private health insurance are economically better off and use more health care services. Over time, the data reveal substantial changes in type of insurance coverage. Conclusions. The data reveal serious vulnerabilities among older Mexican Americans that result from a lack of private Medigap supplemental coverage. (Am J Public Health. 2002;92:1264–1271) In the United States, employer-sponsored health insurance forms the basis of the health care financing system for the majority of working-age adults. For the middle class, private insurance is carried over into retirement, either as a direct retirement benefit or as a purchase made possible by an adequate retirement income. In contrast, for individuals employed in the service sector or in other low-productivity occupations that do not offer retirement or health benefits, or do so only at a cost that is prohibitive to the employee, health coverage in old age is often inadequate. 1 The same factors that influence one’s tie to the labor force and one’s place in it, then, also affect one’s health care coverage in old age. 2 These factors include Hispanic ethnicity, nativity, sex, and age at migration. 3– 6 At every age, a large fraction of Hispanics have either no or only inadequate health care coverage. 5 The situation is particularly serious for individuals of Mexican descent, and especially for the foreign born within this group, who lag far behind non-Hispanics in health insurance coverage. 7– 9 For Hispanics, migration remains a significant component of population growth, and for many immigrants, especially those who come to the United States in mature or late adulthood with little formal education, employment is often restricted to those sectors and occupations that do not offer retirement or health care coverage packages. Even within broad occupational groupings, Hispanics are less likely to have health insurance coverage than are non-Hispanics. In the construction industry, for example, 64% of non-Hispanics hold jobs that offer health insurance, compared with only 46% of Hispanics. 10 These working-age disadvantages place an individual at risk of inadequate health care coverage in old age. 11 Jobs that do not offer benefits to working-age employees are unlikely to provide supplemental Medigap coverage in retirement or to provide enough of a retirement income to make purchasing private coverage possible. Foreign birth and older age at migration only increase this risk. In addition to the educational and occupational handicaps that the foreign born face, individuals who migrate later in life have less time to accumulate assets that might provide economic security and the ability to purchase supplemental health insurance in retirement. 12, 13 Social Security has clearly improved the situation of the elderly relative to younger age groups, but substantial racial and ethnic disparities in income and assets among the elderly persist. Hispanics are disproportionately represented among the poor in the United States across the life cycle, 14– 16 and older Hispanics are far less likely than older nonHispanic Whites to have private pensions or significant assets. 3 Medicare has similarly reduced, but not eliminated, racial and ethnic disparities in access to health care. 17, 18 The relative health care disadvantage that Hispanics face in earlier years persists into old age and has potentially serious health consequences. Medicare premiums and copayments, as well as the portion of hospitalization costs that must be paid by the patient and the cost of uncovered services including prescription drugs, can be substantial. 19 If such costs are too high, individuals may simply do without needed health care. In this report, we examine health insurance coverage and changes in health insurance coverage among older Mexican Americans and identify factors placing individuals at risk of having no or insufficient health insurance within this population. Because people with private Medigap policies have more complete health care coverage than people without it, we were interested in identifying those factors that distinguish older individuals with and without supplemental private insurance. For the impoverished elderly without such private coverage, Medicaid represents the health care safety net. We therefore examine the extent of Medicare and Medicaid coverage among older individuals of Mexican origin. A common assumption is that one’s income and insurance status is fairly well fixed at age 65. By employing longitudinal data, we can examine that assumption as well as changes in the nature and amount of coverage during the latter phases of the life course. Although some health insurance transitions such as acquiring Medicaid as the result of poor health and impoverishment, are predictable, others are not.
