Health-related debt and Health Savings Accounts over time.

This study examines Health Savings Account (HSA) effects on health-related debt outcomes. Applying the health lifestyles theory, a subset of 12,686 respondents from three years (2010, 2012, and 2014) of secondary quantitative data from the National Longitudinal Surveys of Youth (NLSY) was drawn. The sample included respondents who answered survey questions about owning an HSA, chronic disease status, health behavior, and health-related debt. Descriptive, bivariate, and generalized estimating equation (GEE) analyses were conducted. Results indicate HSA ownership status (p = .76) is not significantly associated with reporting health-related debt. Implications for social work practice are discussed.

Income Disparities In Access To Critical Care Services.

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of intensive care unit (ICU) beds in preventing death from the severe respiratory illness associated with COVID-19. However, the availability of ICU beds is highly variable across the US, and health care resources are generally more plentiful in wealthier communities. We examined disparities in community ICU beds by US communities' median household income. We found a large gap in access by income: 49 percent of the lowest-income communities had no ICU beds in their communities, whereas only 3 percent of the highest-income communities had no ICU beds. Income disparities in the availability of community ICU beds were more acute in rural areas than in urban areas. Policies that facilitate hospital coordination are urgently needed to address shortages in ICU hospital bed supply to mitigate the effects of the COVID-19 pandemic on mortality rates in low-income communities.

Why Do Households Lack Emergency Savings? The Role of Financial Capability.

Many U.S. households have insufficient savings to cope with income losses, expenditure shocks, and other financial emergencies, yet little research evidence explains why. Guided by Sherraden (2013) model of financial capability, we expand on prior research that examines the role of financial knowledge by incorporating additional factors and testing income interactions to explain a greater proportion of variance concerning whether or not households have money set aside for emergencies. We analyzed data from the 2009, 2012, 2015, and 2018 National Financial Capability Surveys and found that subjective financial knowledge, financial confidence, and savings account ownership, but not objective financial knowledge, were significant and consistent predictors of having an emergency fund. Savings account ownership was the strongest predictor, accounting for an increase in the probability of having an emergency fund of 25% to 29% across study years. Adding homeownership and ability to cover expenses to the models increased the proportion of variance explained by an average of 29%. Strategies to promote emergency savings should be multifaceted and include help from financial educators and counselors to create greater financial slack as well as programs and policies to increase access to short-term savings opportunities and incentives.

Maternal Cash Transfers Led To Increases In Facility Deliveries And Improved Quality Of Delivery Care In Nigeria.

Ninety-nine percent of global maternal deaths occur in low- and middle-income countries. The high mortality rates are often attributed to a large portion of births occurring outside of formal health care facilities. This has prompted the creation of programs to promote the use of formal delivery care. However, poor-quality care in health facilities in low- and middle-income countries is well documented. It is not clear that shifting births into health facilities in these settings necessarily leads to better-quality care. We present results from a randomized controlled trial in Nigeria that evaluated a conditional cash transfer intervention that paid pregnant women to deliver in a health facility. We found that the intervention led to a 41 percent increase in facility deliveries. We also found improvements in the quality of delivery care (as a result of more births taking place in formal health care settings) and in overall satisfaction with care. We found no evidence of a reduction in preventable complications that led to maternal deaths, though we found some improvements in self-reported health. Our results indicate that promoting facility deliveries can improve the quality of care received, even in settings where formal care quality is poor. However, modest quality improvements might not be sufficient to substantially improve health outcomes.

Lack Of Access To Specialists Associated With Mortality And Preventable Hospitalizations Of Rural Medicare Beneficiaries.

People living in rural areas have worse health outcomes than their urban counterparts do. Understanding what factors account for this could inform policy interventions for reducing rural-urban disparities in health. We examined a nationally representative survey of Medicare beneficiaries with one or more complex chronic conditions, which represented 61 percent of rural and 57 percent of urban Medicare beneficiaries. We found that rural residence was associated with a 40 percent higher preventable hospitalization rate and a 23 percent higher mortality rate, compared to urban residence. Having one or more specialist visits during the previous year was associated with a 15.9 percent lower preventable hospitalization rate and a 16.6 percent lower mortality rate for people with chronic conditions, after we controlled for having one or more primary care provider visits. Access to specialists accounted for 55 percent and 40 percent of the rural-urban difference in preventable hospitalizations and mortality, respectively. Medicare should consider interventions for rural beneficiaries who lack access to specialist care to reduce rural-urban disparities in health outcomes.

Communication Matters: A Long-Term Follow-up Study of Child Savings Account Program Participation.

As they are a long-term policy instrument, the results of many child savings account (CSA) programs take decades to realize. Because of this, important questions regarding the long-term impacts of the programs, as well as participants' perceptions regarding the programs' long-term impacts, are unanswered. In this study, we present findings from a qualitatively driven complex mixed methods follow-up of the first large CSA demonstration project, the quasi-experimental Michigan Saving for Education, Entrepreneurship, and Downpayment (SEED) program. We asked SEED account-holding and non-account-holding families how they communicated about college, saving for college, and future educational attainment, nearly ten years after the CSA demonstration project ended. In a novel approach, we conducted separate semi-structured interviews with dyads of parents and children, combining that information with survey data and account balance monitoring data, ultimately gaining a multidimensional picture of how families with and without SEED accounts were approaching planning for post-secondary education right before the transition to adulthood. We found that: (1) the vast majority of account-holding families did not make withdrawals from their SEED accounts, (2) recent family communication about the SEED accounts was related to the specificity of a child's post-secondary plans, (3) there were tensions between college aspirations and the concrete steps needed to get there, and (4) families voiced concerns regarding the substantial barriers to post-secondary education. These findings point to both the promises and challenges of CSAs that newly developed programs might want to consider.

Health Savings Accounts: Consumer Contribution Strategies and Policy Implications.

Background. Health savings accounts (HSAs) are tax-advantaged savings accounts available only to households with high-deductible health insurance. This article provides initial answers to two questions: 1) How should a household budget for its annual HSA contributions? 2) Do current contribution limits provide households with the flexibility to use HSAs efficiently? To answer these questions, we formulate the household's problem as one of determining a contribution strategy for minimizing total expected discounted medical costs. Methods. We use the 2002-2014 Medical Expenditure Panel Survey to develop a novel data-driven model for forecasting a household's health care costs based on its current cost percentile and other characteristics. A dynamic policy, in which the contribution each year brings the HSA balance up to a household-specific threshold, is derived. This is compared to a simpler static policy in which the target HSA balance is simply the plan's out-of-pocket maximum, with contributions in any year capped by a limit. Results. We find that: 1) the dynamic policy can save a household up to 19% in costs compared to the static one that is a proxy for typical contribution behavior; and 2) the recommended contribution amounts for 9% to 11% of households in a given year materially exceed what is currently allowed by the federal government. Conclusions. The dynamic policy derived from our data-analytic framework is able to unlock significant tax savings for health care consumers. To allow all households to use HSAs in a tax-efficient manner, a two-tiered contribution policy is needed: Allow unlimited contributions up to some balance, and then impose restrictions thereafter. The resulting impact on overall tax receipts is estimated to be well below what is currently allowed by legislation.

Cost-Effectiveness of a Savings-Led Economic Empowerment Intervention for AIDS-Affected Adolescents in Uganda: Implications for Scale-up in Low-Resource Communities.

PURPOSE: Nearly 12 million children and adolescents in sub-Saharan Africa have lost one or both parents to AIDS. Within sub-Saharan Africa, Uganda has been greatly impacted, with an estimated 1.2 million orphaned children, nearly half of which have experienced parental loss due to the epidemic. Cost-effective and scalable interventions are needed to improve developmental outcomes for these children, most of whom are growing up in poverty. This article examines the direct impacts and cost-effectiveness of a savings-led family economic empowerment intervention, Bridges to the Future, that employed varying matched savings incentives to encourage investment in Ugandan children orphaned by AIDS. METHODS: Using data from 48 primary schools in southwestern Uganda, we calculate per-person costs in each of the two treatment arms-Bridges (1:1 match savings) versus Bridges PLUS (1:2 match savings); estimate program effectiveness across outcomes of interest; and provide the ratios of per-person costs to their corresponding effectiveness. RESULTS: At the 24-month postintervention initiation, children in the two treatment arms showed better results in health, mental health, and education when compared to the usual care condition; however, no statistically significant differences were found between treatment arms with the exception of school attendance rates which were higher for those in Bridges PLUS. Owing to the minimal cost difference between the Bridges and Bridges PLUS arms, we did not find substantial cost-effectiveness differences across the two treatment arms. CONCLUSION: After 24 months, an economic intervention that incorporated matched savings yielded positive results on critical development outcomes for adolescents orphaned by AIDS in Uganda. The 1:1 and 1:2 match rates did not demonstrate variable levels of cost-effectiveness at 24-month follow-up, suggesting that governments intending to incorporate savings-led interventions within their social protection frameworks may not need to select a higher match rate to see positive developmental outcomes in the short term. Further research is required to understand intervention impacts and cost-effectiveness after a longer follow-up period.

High-Deductible Health Plans Reduce Health Care Cost And Utilization, Including Use Of Needed Preventive Services.

Enrollment in high-deductible health plans (HDHPs) has greatly increased in recent years. Policy makers and other stakeholders need the best available evidence about how these plans may affect health care cost and utilization, but the literature has not been comprehensively synthesized. We performed a systematic review of methodologically rigorous studies that examined the impact of HDHPs on health care utilization and costs. The plans were associated with a significant reduction in preventive care in seven of twelve studies and a significant reduction in office visits in six of eleven studies-which in turn led to a reduction in both appropriate and inappropriate care. Furthermore, bivariate analyses of data extracted from the included studies suggested that the plans may be associated with a reduction in appropriate preventive care and medication adherence. Current evidence suggests that HDHPs are associated with lower health care costs as a result of a reduction in the use of health services, including appropriate services.

China's medical savings accounts: an analysis of the price elasticity of demand for health care.

Although medical savings accounts (MSAs) have drawn intensive attention across the world for their potential in cost control, there is limited evidence of their impact on the demand for health care. This paper is intended to fill that gap. First, we built up a dynamic model of a consumer's problem of utility maximization in the presence of a nonlinear price schedule embedded in an MSA. Second, the model was implemented using data from a 2-year MSA pilot program in China. The estimated price elasticity under MSAs was between -0.42 and -0.58, i.e., higher than that reported in the literature. The relatively high price elasticity suggests that MSAs as an insurance feature may help control costs. However, the long-term effect of MSAs on health costs is subject to further analysis.

Ahorro infantil: "Chispitas"-Estrategia para combatir la pobreza, Fundación Ayú, Oaxaca, México / Children’s Savings in the Midst of Poverty and Marginalization-"Chispitas: "Chispitas". Estratégia para combater a pobreza, Fundación Ayú, Oaxaca, México / Economia na infância

En esta investigación analizamos cómo la estrategia de combate a la pobreza de la Fundación Ayú, influye en el hábito del ahorro de los niños y niñas mixtecos de Oaxaca -los "Chispitas"-, con datos obtenidos de noviembre de 2013 a julio de 2014. Realizamos un taller participativo y entrevistas semiestructuradas, aplicando un cuestionario a 42 niños y niñas de diez años de edad promedio, y antigüedad como ahorradores de entre tres y siete años. El perfil socioeconómico familiar corresponde mayormente a hogares campesinos; las razones para ahorrar son la educación, el futuro y las emergencias, siendo las madres quienes mayor influencia tienen en este hábito. Participar en las cajas visibiliza a los niños y niñas en la localidad y los inicia en la inclusión social y financiera.

The objective of this research is to analyze how the savings habits of Mixtec children from State of Oaxaca - known as "chispitas" - are influenced by the poverty eradication strategy implemented by the Fundación Ayú. Data collected between November 2013 to July 2014 was used for this purpose. A participatory workshop was held, and semi-structured interviews were conducted using a questionnaire with 42 children that had an an average age of ten, time in education of between one and nine years and have saved for a period of between three and seven years. The children come from families with low socioeconomic status such as farmers and skilled laborers. Their motivation for saving included education, a better future and emergencies.

O objetivo desta pesquisa é analisar como a estratégia de combate à pobreza da Fundación Ayú influencia as crianças do Estado de Oaxaca - os "Chispitas" - no hábito de economizar, com dados obtidos de novembro de 2013 a julho de 2014. Um seminário participativo foi realizado, além de entrevistas semiestruturadas com aplicação de um questionário a 42 crianças com idade média de 10 anos, as quais tinham poupado dinheiro num período de três a sete anos. O perfil socioeconõmico familiar corresponde, em sua maioria, à área rural; as razões para economizar são: educação, futuro e emergências, sendo as mães as principais responsáveis por influenciar nesse hábito. Ter uma poupança faz com o que as crianças iniciem sua inclusão social e financeira em suas famílias.

Health Insurance, Health Savings Accounts and Healthcare Utilization.

Assuming symmetric information, we show that a high-deductible health plan (HDHP) combined with a tax-favored health savings account (HSA) induces more savings and less treatment compared with a full coverage plan under reasonable risk preferences. Furthermore, a higher tax subsidy increases savings in any case but decreases medical utilization if and only if treatment expenses are above the deductible. A larger deductible increases savings but does not necessarily decrease healthcare utilization. Whether an HDHP/HSA combination is preferred over a full coverage contract depends on absolute risk aversion. A higher tax advantage increases the attractiveness of an HDHP/HSA combination, whereas the effects of changes in the deductible are ambiguous. The paper shows that a potential regulator needs to carefully set the size of the deductible as only in a certain corridor of the probability of sickness, its effect on aggregate healthcare costs are unambiguously favorable.

Applying a Family-Level Economic Strengthening Intervention to Improve Education and Health-Related Outcomes of School-Going AIDS-Orphaned Children: Lessons from a Randomized Experiment in Southern Uganda.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

Matched Child Savings Accounts in Low-Resource Communities: Who Saves?

This study examines variations in saving behavior among poor families enrolled in a Child Savings Account program for orphaned and vulnerable school-going children in Uganda. We employ multilevel analyses using longitudinal data from a cluster-randomized experimental design. Our analyses reveal the following significant results: (1) given the average number of months during which the account was open (18 months), families saved on average, USD 54.72, which, after being matched by the program (2:1 match rate) comes to USD 164.16-enough to cover approximately five academic terms of post-primary education; (2) children's saving behavior was not associated with quality of family relations; it was, however, significantly associated with family financial socialization; (3) family demographics were significantly associated with children's saving behavior in the matched Child Savings Account program; and (4) children enrolled in some schools saved better compared to children enrolled in other schools within the same treatment group.

The effect of Health Savings Accounts on group health insurance coverage.

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2-3 percentage point increase in their group insurance coverage.

Optimizing the 'demographic dividend' in young developing countries: The role of contractual savings and insurance for financing education.

Many developing regions are facing a youth bulge, meaning that young people comprise the highest proportion of the population. These regions are at risk of losing what could be a tremendous opportunity for economic growth and development if they do not capitalize on this young and economically productive population - also referred to as the "demographic dividend," defined as the increase in economic growth that tends to follow increases in the ratio of the working-age population - essentially the labor force - to dependents. Nations undergoing this population transition have the opportunity to capitalize on the demographic dividend if the right social, economic, and human capital policies are in place. In particular, sub-Saharan Africa, the Middle East, and North Africa are at risk of losing the demographic dividend. These regions face high youth unemployment, low primary school completion, and low secondary school enrollment. This results in an undereducated and unskilled segment of the population. The prohibitive costs of education prevent young people from finishing school, thereby entering the labor market unprepared. This article presents a case for youth-focused financial inclusion programs as one of the antidotes to the masses of poor, undereducated, and low-skilled young people swelling the labor markets of poor developing countries.

Do Savings Mediate Changes in Adolescents' Future Orientation and Health-Related Outcomes? Findings From Randomized Experiment in Uganda.

PURPOSE: This present study tests the proposition that an economic strengthening intervention for families caring for AIDS-orphaned adolescents would positively affect adolescent future orientation and psychosocial outcomes through increased asset accumulation (in this case, by increasing family savings). METHODS: Using longitudinal data from the cluster-randomized experiment, we ran generalized estimating equation models with robust standard errors clustering on individual observations. To examine whether family savings mediate the effect of the intervention on adolescents' future orientation and psychosocial outcomes, analyses were conducted in three steps: (1) testing the effect of intervention on mediator; (2) testing the effect of mediator on outcomes, controlling for the intervention; and (3) testing the significance of mediating effect using Sobel-Goodman method. Asymmetric confidence intervals for mediated effect were obtained through bootstrapping-to address the assumption of normal distribution. RESULTS: Results indicate that participation in a matched Child Savings Account (CSA) program improved adolescents' future orientation and psychosocial outcomes by reducing hopelessness, enhancing self-concept, and improving adolescents' confidence about their educational plans. However, the positive intervention effect on adolescent future orientation and psychosocial outcomes was not transmitted through saving. In other words, participation in the matched CSA program improved adolescent future orientation and psychosocial outcomes regardless of its impact on reported savings. CONCLUSIONS: Further research is necessary to understand exactly how participation in economic strengthening interventions, for example, those that employ matched CSAs, shape adolescent future orientation and psychosocial outcomes: what, if not savings, transmits the treatment effect and how?

Poor Families Striving to Save in Matched Children's Savings Accounts: Findings from a Randomized Experimental Design in Uganda.

This study examines participants' savings in children's savings accounts (CSAs) set up for AIDS-orphaned children ages 10-15 in Uganda. Using a cluster randomized experimental design, we examine the extent to which families participating in a CSA program report more savings than their counterparts not participating in the program, explore the extent to which families who participate in the CSA program report using formal financial institutions compared with families who do not have a CSA, and consider whether families participating in the CSA program bring new money into the CSA or whether they reshuffle existing household assets. We find that participating in a CSA increased families' likelihood to report having saved money. However, our results show no intervention effect either on the amount of self-reported savings or on the likelihood of using formal financial institutions. Further research is needed to understand whether use of a CSA helps families generate new wealth.

Family economic strengthening and mental health functioning of caregivers for AIDS-affected children in rural Uganda.

In sub-Saharan Africa, many extended families assume the role of caregivers for children orphaned by AIDS (AIDS-affected children). The economic and psychological stress ensued from caregiving duties often predispose caregivers to poor mental health outcomes. Yet, very few studies exist on effective interventions to support these caregivers. Using data from a randomized controlled trial called Suubi-Maka (N = 346), this paper examines whether a family economic strengthening intervention among families caring for AIDS-affected children (ages 12-14) in Uganda would improve the primary caregivers' mental health functioning. The Suubi-Maka study comprised of a control condition (n = 167) receiving usual care for AIDS-affected children, and a treatment condition (n = 179) receiving a family economic strengthening intervention, including matched savings accounts, and financial planning and management training to incentivize families to save money for education and/or family-level income generating projects. This paper uses data from baseline/pre-intervention (wave 1) interviews with caregivers and 12-month post-intervention initiation (wave 2). The caregiver's mental health measure adapted from previous studies in sub- Saharan Africa had an internal consistency of .88 at wave 1 and .90 at wave 2. At baseline, the two study groups did not significantly differ on caregiver's mental health functioning. However, at 12-month follow-up, multiple regression analysis located significant differences between the two study groups on mental health functioning. Specifically, following the intervention, caregivers in the treatment condition reported positive improvements on their mental health functioning, especially in the symptom areas of obsession-compulsion, interpersonal sensitivity, hostility, and psychoticism. Findings point to a need for programs and policies aimed at supporting caregivers of AIDS-affected children to begin to consider incorporating family-level economic strengthening components in their usual care protocols, especially in low-resource countries of sub-Saharan Africa. Economic empowerment programming may help enhance the well-being of caregivers and their families.