1. How does Health Insurance Buffer the Consequences of Intimate Partner Violence in Ohio? Kenneth J. Steinman, PhD, MPH Phyllis Pirie, PHD The Ohio State University College of Public Health Erinn M. Hade, MS The Ohio State University Center for Biostatistics July 29, 2011 Ohio Employer and Ohio Family Health Research Conference

2. Background IPV (intimate partner violence) is associated with greater health care utilization –$943 million / year (Corso et al., 2007) Common data sources –Insurance claims data (e.g., Coker; Rivara) –Surveys (e.g., Breiding; Tjaeden)

3. Three Questions How common is IPV among select groups? How is IPV associated with adverse consequences? Does the association of IPV with emergency room use vary by insurance type?

4. Policy Implications Cost of covering the uninsured –Medicaid vs. employer-sponsored insurance Value of health-care-based IPV intervention

5. Ohio Family Health Survey Conducted most recently in 2008 & 2010 Computer-Assisted Telephone Interviews Random Digit Dialing Over-sampling of ethnic minorities, select counties Representative of Ohio adults & households

6. Ohio Family Health Survey 20082010 n (women 18-64) 50,944 (23,083) 8,276 (3,468) Response rate34.6%42.7% / 21.9%

7. Outcomes Financial distress –During the last 12 months, were there times when you had problems paying or were unable to pay for medical bills for yourself or anyone else in the family or household? Serious psychological distress –During the past 30 days, how often did you feel so sad that nothing would cheer you up? Unmet health needs –Did you delay or avoid getting care that you needed, but that you could not afford? Fair or poor self rated health status –In general, would you say your health is excellent, very good, good, fair, or poor? ER use –During the past 12 months, how many times were you a patient in a hospital emergency room?

8. Intimate Partner Violence Only measured physical abuse Past year Different measures in 2008, 2010

9. IPV measure - 2008 During the past 12 months, how many times, if any, has anyone hit, slapped, pushed, kicked or physically hurt you? Think about the time of the most recent incident involving a person or persons who hit, slapped, pushed, kicked or physically hurt you. What was that person’s relationship to you? (open-ended)

10. What was that person’s relationship to you? IPV measure - 2008 0 times 1+ times 04 Male/Female first date 05 Someone you were dating 06 Former boyfriend/girlfriend 07 Current boyfriend/girlfriend or fiancé 08 Spouse or live-in partner 09 Former spouse or live-in partner How many times…? intimate partner violence 01 Stranger 02 Coworker 03 Professional caretaker 10 S/he is my Child 11 S/he is my Stepchild 12 Another family member 13 Acquaintance/friend 97 OTHER 98 DK 99 REFUSED Other violence Not a case

11. IPV measure - 2010 Has an intimate partner EVER used physical violence against you? This includes hitting, slapping, pushing, kicking, or hurting you in any way. When was the last time an intimate partner used physical violence against you?

12. Other Variables Age, ethnicity, region, marital status Socioeconomic status –Income, education Insurance status –Uninsured; Medicaid; Employer-sponsored; Other

13. Data Analysis Generalized Linear Model –Poisson distribution, log link –Controlling for age, ethnicity, income, education, marital status Weighted data; complex survey design

14. Three Questions How common is IPV among select groups? How is IPV associated with adverse consequences? Does the association of IPV with emergency room use vary by insurance type?

15. IPV prevalence LifetimePast-year Unweighted nPrevalence95% CIPrevalence95% CI Men2,3518.8%7.5-10.13.1%2.3-4.0 Women3,47318.4%16.9-19.92.5%1.8-3.2

16. Past-Year IPV prevalence among women nWeighted %95%CI Uninsured5005.3[2.9-7.7] Medicaid4706.0[3.0-8.5] ESI (self)1,2821.2[0.4-2.0] ESI (spouse)7990.5[0.0-1.1] Other insurance4222.3[0.5-4.1] Veterans791.4[0.0-4.3] Non-Veterans3,3942.5[1.8-3.2] In relationship with women 13--

17. Ohio women experiencing past-year IPV: Proportions by insurance type N=94,465

18. IPV past-year prevalence 20082010 Women 18-641.8%2.5% Uninsured4.5%5.3% Medicaid5.2%6.0% ESI0.7%0.9%

19. Three Questions How common is IPV among select groups? How is IPV associated with adverse consequences? Does the association of IPV with emergency room use vary by insurance type?

20. Prevalence of adverse consequences by length of time since most recent IPV Note: results are unadjusted

21. Prevalence ratios (with 95%CI) of IPV with adverse consequences PR=Prevalence Ratio, adjusted for age, ethnicity, income, education, marital status Prevalence Ratio Estimate95%CI Serious psychological distress1.4[1.1-1.8] Fair/Poor self-rated health status1.2[0.8-1.8] Financial distress1.3[1.0-1.6]

22. Three Questions How common is IPV among select groups? How is IPV associated with adverse consequences? Does the association of IPV with emergency room use vary by insurance type?

23. Association of IPV with ER Use: Variation by Insurance Status PR=Prevalence Ratio, adjusted for age, ethnicity, income, education, marital status UninsuredMedicaid Employer- SponsoredOther PR 95% CI PR 95% CI PR 95% CI PR 95% CI 20081.7 [1.3-2.3] 1.4 [1.1-1.7] 1.4 [0.9-2.2] 1.9 [1.1-3.2] 20101.9 [1.4-2.5] 1.0 [0.7-1.6] 0.8 [0.4-1.7] 0.8 [0.3-2.5]

24. Discussion IPV prevalence varies by insurance status IPV – ER use association varies by insurance status Less ability to pay  delayed utilization  more severe abuse  greater utilization

25. Implications Providing health insurance to uninsured women may reduce ER use costs Other studies may underestimate IPV-HCU association Include insurance as a component of SES Supports value of health-care-based intervention

26. Thank you kjsteinman@gmail.com