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1.  New evidence on financing equity in China's health care reform - A case study on Gansu province, China 
In the transition from a planned economy to a market-oriented economy, China’s state funding for health care declined and traditional coverage plans collapsed, leaving China’s poor exposed to potentially ruinous health care costs. In reforming health care for the 21st century, equity in health care financing has become a major policy goal. To assess progress towards this goal, this paper examines the equity characteristics of health care financing in a province of northwestern China, comparing the equity performance between urban and rural areas at two different points in time.
Analysis of whether health care financing contributions were progressive according to income were made using the Kakwani index for each of the four health care financing channels of general taxes, public and private health insurance, and out-of-pocket payments. Two rounds of surveys were conducted, the first in 2003 (13,619 individuals in 3946 households) and the second in 2008 (12,973 individuals in 3958 households). Household socio-economic, health care payment, and utilization information were recorded in household interviews.
Low-income households have undertaken a larger share of the health care financing burden in recent years, reflected by negative Kakwani indices, which indicate a regressive system. We found that the indices for general taxation were −0.0024 (urban) and −0.0281 (rural) in 2002, and −0.0177 (urban) and −0.0097 (rural) in 2007. Public health insurance presented different financing distributions in urban and rural areas (urban: 0.0742 in 2002, 0.0661 in 2007; rural: –0.0615 in 2002,–0.1436 in 2007.). Out-of-pocket payments were progressive but not equitable. Public health insurance coverage has expanded but financing equity has decreased.
Health care financing policies in China need ongoing reform. Given the inequity of general consumption taxes, elimination of these would improve financing equity considerably. Optimizing benefit packages in public health insurance is as important as expanding coverage, both for health care financing and for utilization management as well. Although they are progressive, out-of-pocket payments are not equitable in China and have the effect of excluding the poor from health care as they cannot afford to pay for medical care and so withdraw from treatment.
PMCID: PMC3562140  PMID: 23244513
Equity; Chinese health care reform; Financing; Kakwani index
2.  Health financing reform in Uganda: How equitable is the proposed National Health Insurance scheme? 
Uganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.
We reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.
The introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.
Under the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.
PMCID: PMC2967551  PMID: 20942899
3.  The Effect of Massachusetts’ Health Reform on Employer-Sponsored Insurance Premiums* 
In this paper, we use publicly available data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to investigate the effect of Massachusetts’ health reform plan on employer-sponsored insurance premiums. We tabulate premium growth for private-sector employers in Massachusetts and the United States as a whole for 2004 – 2008. We estimate the effect of the plan as the difference in premium growth between Massachusetts and the United States between 2006 and 2008—that is, before versus after the plan—over and above the difference in premium growth for 2004 to 2006. We find that health reform in Massachusetts increased single-coverage employer-sponsored insurance premiums by about 6 percent, or $262. Although our research design has important limitations, it does suggest that policy makers should be concerned about the consequences of health reform for the cost of private insurance.
PMCID: PMC3251220  PMID: 22229023
health reform
4.  Effect of private insurance incentive policy reforms on trends in coronary revascularisation procedures in the private and public health sectors in Western Australia: a cohort study 
The Australian federal government introduced private health insurance incentive policy reforms in 2000 that increased the uptake of private health insurance in Australia. There is currently a lack of evidence on the effect of the policy reforms on access to cardiovascular interventions in public and private hospitals in Australia. The aim was to investigate whether the increased private health insurance uptake influenced trends in emergency and elective coronary artery revascularisation procedures (CARPs) for private and public patients.
We included 34,423 incident CARPs from Western Australia during 1995-2008 in this study. Rates of emergency and elective CARPs were stratified for publicly and privately funded patients. The average annual percent change (AAPC) in trend was calculated before and after 2000 using joinpoint regression.
The rate of emergency CARPs, which were predominantly percutaneous coronary interventions (PCIs) with stenting, increased throughout the study period for both public and private patients (AAPC=12.9%, 95% CI=5.0,22.0 and 14.1%, 95% CI=9.8,18.6, respectively) with no significant difference in trends before and after policy implementation. The rate of elective PCIs with stenting from 2000 onwards remained relatively stable for public patients (AAPC=−6.0, 95% C= −16.9,6.4), but increased by 4.1% on average annually (95% CI=1.8,6.3) for private patients (pdifference=0.04 between groups). This rate increase for private patients was only seen in people aged over 65 years and people residing in high socioeconomic areas.
The private health insurance incentive policy reforms are a likely contributing factor in the shift in 2000 from public to privately-funded elective PCIs with stenting. These reforms as well as the increasing number of private hospitals may have been successful in increasing the availability of publicly-funded beds since 2000.
PMCID: PMC3729369  PMID: 23870450
Health insurance; Coronary artery disease; Revascularisation procedures; Health policy
5.  Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya 
Health insurance is currently being considered as a mechanism for promoting progress to universal health coverage (UHC) in many African countries. The concept of health insurance is relatively new in Africa, it is hardly well understood and remains unclear how it will function in countries where the majority of the population work outside the formal sector. Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. Progress has been slow, but commitment to achieve UHC through a NHIS remains. This study contributes to this process by exploring communities’ understanding and perceptions of health insurance and their preferred designs features. Communities are the major beneficiaries of UHC reforms. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability.
Data presented in this paper are part of a study that explored feasibility of health insurance in Kenya. Data collection methods included a cross-sectional household survey (n = 594 households) and focus group discussions (n = 16).
About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.
This study provides important information on community understanding and perceptions of health insurance. As Kenya continues to prepare for UHC, it is important that communities are educated and engaged to ensure that the NHIS is acceptable to the population it serves.
PMCID: PMC3842821  PMID: 24219335
6.  Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003 
In 1997 there was a major reform of the government run urban health insurance system in China. The principal aims of the reform were to widen coverage of health insurance for the urban employed and contain medical costs. Following this reform there has been a transition from the dual system of the Government Insurance Scheme (GIS) and Labour Insurance Scheme (LIS) to the new Urban Employee Basic Health Insurance Scheme (BHIS).
This paper uses data from the National Health Services Surveys of 1998 and 2003 to examine the impact of the reform on population coverage. Particular attention is paid to coverage in terms of gender, age, employment status, and income levels. Following a description of the data between the two years, the paper will discuss the relationship between the insurance reform and the growing inequities in population coverage.
An examination of the data reveals a number of key points:
a) The overall coverage of the newly established scheme has decreased from 1998 to 2003.
b) The proportion of the urban population without any type of health insurance arrangement remained almost the same between 1998 and 2003 in spite of the aim of the 1997 reform to increase the population coverage.
c) Higher levels of participation in mainstream insurance schemes (i.e. GIS-LIS and BHIS) were identified among older age groups, males and high income groups. In some cases, the inequities in the system are increasing.
d) There has been an increase in coverage of the urban population by non-mainstream health insurance schemes, including non-commercial and commercial ones.
The paper discusses three important issues in relation to urban insurance coverage: institutional diversity in the forms of insurance, labour force policy and the non-mainstream forms of commercial and non-commercial forms of insurance.
The paper concludes that the huge economic development and expansion has not resulted in a reduced disparity in health insurance coverage, and that limited cross-group subsidy and regional inequality is possible. Unless effective measures are taken, vulnerable groups such as women, low income groups, employees based on short-term contracts and rural-urban migrant workers may well be left out of sharing the social and economic development.
PMCID: PMC1828155  PMID: 17335584
7.  Accelerated reforms in healthcare financing: the need to scale up private sector participation in Nigeria 
The health sector, a foremost service sector in Nigeria, faces a number of challenges; primarily, the persistent under-funding of the health sector by the Nigerian government as evidence reveals low allocations to the health sector and poor health system performance which are reflected in key health indices of the country.Notwithstanding, there is evidence that the private sector could be a key player in delivering health services and impacting health outcomes, including those related to healthcare financing. This underscores the need to optimize the role of private sector in complementing the government’s commitment to financing healthcare delivery and strengthening the health system in Nigeria. There are also concerns about uneven quality and affordability of private-driven health systems, which necessitates reforms aimed at regulation. Accordingly, the argument is that the benefits of leveraging the private sector in complementing the national government in healthcare financing outweigh the challenges, particularly in light of lean public resources and finite donor supports. This article, therefore, highlights the potential for the Nigerian government to scale up healthcare financing by leveraging private resources, innovations and expertise, while working to achieve the universal health coverage.
PMCID: PMC3937949  PMID: 24596895
Nigeria; Healthcare Financing; Health System; Private Sector
8.  Health Care Reform Hinges on Private-Sector Collaboration 
Preventing Chronic Disease  2009;6(2):A74.
America's health care system is characterized by rising costs, increasing numbers of Americans who lack health insurance coverage, and poor quality of health care delivery. The convergence of these factors is adversely affecting not only the health of Americans but also the ability of businesses to compete successfully in a global marketplace. AARP and other nonprofit organizations are collaborating with the private sector to have more people covered by health insurance and to educate them to make behavioral choices that prevent chronic disease and ultimately lower costs.
PMCID: PMC2687880  PMID: 19289017
9.  Massachusetts Health Reform and Disparities in Coverage, Access and Health Status 
Journal of General Internal Medicine  2010;25(12):1356-1362.
Massachusetts health reform has achieved near-universal insurance coverage, yet little is known about the effects of this legislation on disparities.
Since racial/ethnic minorities and low-income individuals are over-represented among the uninsured, we assessed the effects of health reform on disparities.
Cross-sectional survey data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 2006–2008.
Adults from Massachusetts (n = 36,505) and other New England states (n = 63,263).
Main Measures
Self-reported health coverage, inability to obtain care due to cost, access to a personal doctor, and health status. To control for trends unrelated to reform, we compared adults in Massachusetts to those in all other New England states using multivariate logistic regression models to calculate adjusted predicted probabilities.
Key Results
Overall, the adjusted predicted probability of health coverage in Massachusetts rose from 94.7% in 2006 to 97.7% in 2008, whereas coverage in New England remained around 92% (p < 0.001 for difference-in-difference). While cost-related barriers were reduced in Massachusetts, there were no improvements in access to a personal doctor or health status. Although there were improvements in coverage and cost-related barriers for some disadvantaged groups relative to trends in New England, there was no narrowing of disparities in large part because of comparable or larger improvements among whites and the non-poor.
Achieving equity in health and health care may require additional focused intervention beyond health reform.
PMCID: PMC2988151  PMID: 20730503
health coverage; health care reform; Massachusetts
10.  Oral Health Care Reform in Finland – aiming to reduce inequity in care provision 
BMC Oral Health  2008;8:3.
In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.
National registers were used as data sources for the study. Use of dental services, personnel resources and costs in 2000 (before the reform) and in 2004 (after the reform) were compared.
In 2000, when access to publicly subsidised dental services was restricted to those born in 1956 or later, every third adult used the PDS or subsidised private services. By 2004, when subsidies had been extended to the whole adult population, this increased to almost every second adult. The PDS reported having seen 118 076 more adult patients in 2004 than in 2000. The private sector had the same number of patients but 542 656 of them had not previously been entitled to partial reimbursement of fees.
The use of both public and subsidised private services increased most in big cities and urban municipalities where access to the PDS had been poor and the number of private practitioners was high. The PDS employed more dentists (6.5%) and the number of private practitioners fell by 6.9%. The total dental care expenditure (PDS plus private) increased by 21% during the study period. Private patients who had previously not been entitled to reimbursements seemed to gain most from the reform.
The results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly.
PMCID: PMC2268684  PMID: 18226197
11.  Analysis of government investment in primary healthcare institutions to promote equity during the three-year health reform program in China 
The World Health Report 2000 stated that increased public financing for healthcare was an integral part of the efforts to achieve equity of access. In 2009, the Chinese government launched a three-year health reform program to achieve equity of access. Through this reform program, the government intended to increase its investment in primary healthcare institutions (PHIs). However, reports about the outcome and the improvement of the equity of access have yet to be presented.
Stratified sampling was employed in this research. The samples used for the study comprised 34 community health service centers (CHSCs) and 92 township hospitals (THs) from six provinces of China. Collected data, which were publicly available, consisted of the total revenue, financial revenue, and the number of people for the periods covering January 2010 to September 2010 and January 2011 to September 2011. Revenue information for 2009 and 2010 was obtained from China’s Health Statistics Yearbook.
By using indicators such as government investment, government finance proportion and per capita revenue, t-tests for paired and independent samples were used to analyze the changes in government investment.
Government invest large amount of money to the primary healthcare institutions. Government finance proportion in 2008 was 18.2%. This percentage increased to 38.84% in 2011, indicating statistical significance (p = 0.000) between 2010 and 2011. The per capita financial input was 20.92 yuan in 2010 and 31.10 yuan in 2011. Compared with the figures from 2008 to 2010, the gap in different health sectors narrowed in 2011, and differences emerged. The government finance proportion in CHSCs revenue was 6.9% higher than that of THs, while the per capita revenue of CHSCs was higher. In 2011, the highest and lowest government finance proportions were 48.80% (Shaanxi) and 19.36% (Shandong), respectively. In that same year, the per capita revenue of Shaanxi (40.69 Yuan) was higher than that of Liaoning (28.79 Yuan). Comparing the 2011 figures with those from 2008 to 2010, the gap in 2011 clearly narrowed.
In the three-year health reform program, the Chinese government increased its investment to PHIs gradually and significantly. Thus promote equity to access and universal coverage. However, the increase in government investment stemmed from political desire and from the lack of institutionalization of practice and experience. Hence, a mode of financial allocation must be formulated to promote consistency in government input after the three-year health reform program.
PMCID: PMC3614483  PMID: 23530658
12.  The effect of health insurance reform on the number of cataract surgeries in Chongqing, China 
Cataracts are the leading cause of blindness in China, and poverty is a major barrier to having cataract surgery. In 2003, the Chinese government began a series of new national health insurance reforms, including the New Cooperative Medical Scheme (NCMS) and the Urban Resident Basic Health Insurance scheme (URBMI). These two programs, combined with the previously existing Urban Employee Basic Health Insurance (UEBMI) program, aimed to make it easier for individuals to receive medical treatment. This study reports cataract surgery numbers in rural and urban populations and the proportion of these who had health insurance in Chongqing, China from 2003 to 2008.
The medical records of a consecutive case series, including 14,700 eyes of 13,262 patients who underwent age-related cataract surgery in eight hospitals in Chongqing from January 1, 2003, to December 31, 2008, were analysed retrospectively via multi-stage cluster sampling.
In the past six years, the total number of cataract surgeries had increased each year as had the number of patients with insurance. Both the number of surgeries and the number of insured patients were much higher in the urban group than in the rural group. The rate of increase in the rural group however was much higher than in the urban group, especially in 2007 and 2008. The odds ratios of having health insurance for urban vs. rural individuals were relatively stable from 2003 to 2006, but it decreased in 2007 and was significantly lower in 2008.
Health insurance appears to be an important factor associated with increased cataract surgery in Chongqing, China. With the implementation of health insurance, the number of Chongqing's cataract surgeries was increased year by year.
PMCID: PMC3072314  PMID: 21439077
13.  The Mission of Safety Net Organizations Following National Insurance Reform 
National health insurance reform will pose considerable challenges to the core missions of safety net organizations that serve the uninsured. Those who currently donate money or time will, rightly or wrongly, view uninsured recipients as less deserving on the whole. Nevertheless, safety net organizations can serve several critical functions that continue to justify their existence and support.
One important mission is to maintain access for low-income uninsured until all elements of insurance reform are fully in place. Second, once the reform is implemented, people will need a great deal of assistance and encouragement to determine what they are supposed to do and where they are supposed to sign up. Third, substantial portions of the remaining uninsured will continue to lack affordable insurance options, and large numbers of people eligible for coverage will unavoidably undergo temporary gaps in coverage as their family and financial circumstances change. Finally, not all people with insurance will have affordable access to all needed care. Market conditions will continue pushing higher levels of patient cost-sharing through deductibles and co-payments.
To serve these multiple needs, safety net organizations should consider adapting their missions and business models so that they accept both insured and uninsured patients under a sliding fee scale that varies charges according to ability to pay.
PMCID: PMC3138599  PMID: 21442337
uninsured; safety net; insurance reform
14.  US Spending On Complementary And Alternative Medicine During 2002–08 Plateaued, Suggesting Role In Reformed Health System 
Health affairs (Project Hope)  2013;32(1):45-52.
Complementary and alternative medicine services in the United States are an approximately $9 billion market each year, equal to 3 percent of national ambulatory health care expenditures. Unlike conventional allopathic health care, complementary and alternative medicine is primarily paid for out of pocket, although some services are covered by most health insurance. Examining trends in demand for complementary and alternative medicine services in the United States reported in the Medical Expenditure Panel Survey during 2002–08, we found that use of and spending on these services, previously on the rise, have largely plateaued. The higher proportion of out-of-pocket responsibility for payment for services may explain the lack of growth. Our findings suggest that any attempt to reduce national health care spending by eliminating coverage for complementary and alternative medicine would have little impact at best. Should some forms of complementary and alternative medicine—for example, chiropractic care for back pain—be proven more efficient than allopathic and specialty medicine, the inclusion of complementary and alternative medicine providers in new delivery systems such as accountable care organizations could help slow growth in national health care spending.
PMCID: PMC3644505  PMID: 23297270
15.  Wisconsin's BadgerCare Plus Reform: Impact on Low-Income Families' Enrollment and Retention in Public Coverage 
Health Services Research  2011;46(1p2):336-347.
To examine the impact of a Wisconsin health care reform enacted in early 2008 on public insurance enrollment and retention.
Data Sources
Administrative data covering the period January 2007 to November 2009.
Study Design
We calculate unadjusted enrollment trends and exit rates stratified by age, income group, and enrollment mode. Kaplan–Meier curves and Cox proportional hazards models are estimated to assess the impact of the reform on program exits.
Principal Findings
Overall enrollment increased by approximately one-third and exit rates decreased by approximately one-fifth. The majority of new enrollment came from the previously income eligible.
Wisconsin's enactment of eligibility expansions coupled with administrative simplification and targeted marketing and outreach efforts were successful in enrolling and retaining low-income children and families in public coverage.
PMCID: PMC3037786  PMID: 21143476
Medicaid expansions; health care reform; health insurance
16.  Changes in health expenditures in China in 2000s: has the health system reform improved affordability 
China's health system reform launched in early 2000s has achieved better coverage of health insurance and significantly increased the use of healthcare for vast majority of Chinese population. This study was to examine changes in the structure of total health expenditures in China in 2000–2011, and to investigate the financial burden of healthcare placed on its population, particularly between urban and rural areas and across different socio-economic development regions.
Health expenditures data came from the China National Health Accounts study in 1990–2011, and other data used to calculate the financial burden of healthcare were from China Statistical Yearbook and China Population Statistical Yearbook. Total health expenditures were divided into government and social expenditure, and out-of-pocket payment. The financial burden of healthcare was estimated as out-of-pocket payment per capita as a percentage of annual household living consumption expenditure per capita.
Between 2000 and 2011, total health expenditures in China increased from Chinese yuan 319 to 1888 (United States dollars 51 to 305), with average annual increase of 17.4%. Government and social health expenditure increased rapidly being 22.9% and 18.8% of average annual growth rate, respectively. The share of out-of-pocket payment in total health expenditure for the urban population declined from 53% in 2005 to 36% in 2011, but had only a slight decrease for the rural population from 53% to 50%. Out-of-pocket payment, as a percentage of annual household living consumption, has continued to rise, particularly in the rural population from the less developed region (6.1% in 2000 to 8.8% in 2011).
The rapid increase of public funding to subsidize health insurance in China, as part of the reform strategy, did not mitigate the out-of-pocket payment for healthcare over the past decade. Financial burden of healthcare on the rural population increased. Affordability among the rural households with sick members, particularly in the less developed region, is getting worse. It needs effective measures on cost control including healthcare provider payment reform and well developed health insurance schemes to offer better financial protection for the vulnerable Chinese seeking essential healthcare.
PMCID: PMC3686675  PMID: 23764104
Health expenditures; Financial burden; Rural population; China
17.  Interactions: Trade Policy and Healthcare Reform After Chaoulli v. Quebec 
Healthcare Policy  2006;1(2):90-102.
The insulation of Canada’s healthcare system from trade treaty obligations is crucial to the legitimacy of Canada’s trade policy. Legal analysis has suggested, however, that competitive and for-profit delivery of the kind contemplated by the Kirby Report and some provinces may make healthcare more vulnerable to challenges under NAFTA and GATS. The Government of Canada has tried to counter this interpretation by stressing the importance of public financing as the principal criterion for exemption of healthcare from trade treaties, but now the potential for private financing of essential medical services indicated by the Supreme Court’s decision in Chaoulli v. Quebec has made that line of argument look risky as well. It is apparent that Canada failed to anticipate the possible interactions of domestic, international and constitutional law when it made commitments in the area of private health insurance at the WTO in 1997. Accordingly, the time has come to acknowledge the fragility of the boundary between health and trade policies, to take the risks and costs associated with trade treaty obligations fully into account when undertaking healthcare reform and to strengthen the separation between private and public health insurance.
PMCID: PMC2585326  PMID: 19305659
18.  The political economy of healthcare reform in China: negotiating public and private 
SpringerPlus  2013;2:448.
China’s healthcare system is experiencing significant growth from expanded government-backed insurance, greater public-sector spending on hospitals, and the introduction of private insurance and for-profit clinics. An incremental reform process has sought to develop market incentives for medical innovation and liberalize physician compensation and hospital finance while continuing to keep basic care affordable to a large population that pays for many components of care out-of-pocket. Additional changes presently under consideration by policymakers are likely to further restructure insurance and the delivery of care and will alter competitive dynamics in major healthcare industries, notably pharmaceuticals, medical devices, and diagnostic testing. This article describes the institutional history of China’s healthcare system and identifies dilemmas emerging as the country negotiates divisions between public and private in healthcare. Building on this analysis, the article considers opportunities for public-private partnerships and greater systems integration to reconcile otherwise incommensurable approaches to rewarding innovation and improving access. The article concludes with observations on the public function of health insurance and its significance to further development of China’s healthcare system.
PMCID: PMC3776089  PMID: 24052932
China; Healthcare reform; Clinical trials; Electronic medical records; Insurance; Pharmaceuticals
19.  California's “Bridge to Reform”: Identifying Challenges and Defining Strategies for Providers and Policymakers Implementing the Affordable Care Act in Low-Income HIV/AIDS Care and Treatment Settings 
PLoS ONE  2014;9(3):e90306.
In preparation for full Affordable Care Act implementation, California has instituted two healthcare initiatives that provide comprehensive coverage for previously uninsured or underinsured individuals. For many people living with HIV, this has required transition either from the HIV-specific coverage of the Ryan White program to the more comprehensive coverage provided by the county-run Low-Income Health Programs or from Medicaid fee-for-service to Medicaid managed care. Patient advocates have expressed concern that these transitions may present implementation challenges that will need to be addressed if ambitious HIV prevention and treatment goals are to be achieved.
30 semi-structured, in-depth interviews were conducted between October, 2012, and February, 2013, with policymakers and providers in 10 urban, suburban, and rural California counties. Interview topics included: continuity of patient care, capacity to handle payer source transitions, and preparations for healthcare reform implementation. Study team members reviewed interview transcripts to produce emergent themes, develop a codebook, build inter-rater reliability, and conduct analyses.
Respondents supported the goals of the ACA, but reported clinic and policy-level challenges to maintaining patient continuity of care during the payer source transitions. They also identified strategies for addressing these challenges. Areas of focus included: gaps in communication to reach patients and develop partnerships between providers and policymakers, perceived inadequacy in new provider networks for delivering quality HIV care, the potential for clinics to become financially insolvent due to lower reimbursement rates, and increased administrative burdens for clinic staff and patients.
California's new healthcare initiatives represent ambitious attempts to expand and improve health coverage for low-income individuals. The state's challenges in maintaining quality care and treatment for people living with HIV experiencing these transitions demonstrate the importance of setting effective policies in anticipation of full ACA implementation in 2014.
PMCID: PMC3943953  PMID: 24599337
20.  Basing care reforms on evidence: The Kenya health sector costing model 
The Government of the Republic of Kenya is in the process of implementing health care reforms. However, poor knowledge about costs of health care services is perceived as a major obstacle towards evidence-based, effective and efficient health care reforms. Against this background, the Ministry of Health of Kenya in cooperation with its development partners conducted a comprehensive costing exercise and subsequently developed the Kenya Health Sector Costing Model in order to fill this data gap.
Based on standard methodology of costing of health care services in developing countries, standard questionnaires and analyses were employed in 207 health care facilities representing different trustees (e.g. Government, Faith Based/Nongovernmental, private-for-profit organisations), levels of care and regions (urban, rural). In addition, a total of 1369 patients were randomly selected and asked about their demand-sided costs. A standard step-down costing methodology was applied to calculate the costs per service unit and per diagnosis of the financial year 2006/2007.
The total costs of essential health care services in Kenya were calculated as 690 million Euros or 18.65 Euro per capita. 54% were incurred by public sector facilities, 17% by Faith Based and other Nongovernmental facilities and 23% in the private sector. Some 6% of the total cost is due to the overall administration provided directly by the Ministry and its decentralised organs. Around 37% of this cost is absorbed by salaries and 22% by drugs and medical supplies. Generally, costs of lower levels of care are lower than of higher levels, but health centres are an exemption. They have higher costs per service unit than district hospitals.
The results of this study signify that the costs of health care services are quite high compared with the Kenyan domestic product, but a major share are fixed costs so that an increasing coverage does not necessarily increase the health care costs proportionally. Instead, productivity will rise in particular in under-utilized private health care institutions. The results of this study also show that private-for-profit health care facilities are not only the luxurious providers catering exclusively for the rich but also play an important role in the service provision for the poorer population. The study findings also demonstrated a high degree of cost variability across private providers, suggesting differences in quality and efficiencies.
PMCID: PMC3129293  PMID: 21619567
21.  How Did Welfare Reform Affect the Health Insurance Coverage of Women and Children? 
Health Services Research  2006;41(2):486-506.
To measure the change in U.S. women and children's health insurance coverage as a result of welfare reform (i.e. the creation of Temporary Assistance for Needy Families or TANF) in 1996.
Data Source
1992–1999 longitudinal data from the Survey of Income and Program Participation (SIPP) merged with data on the timing of state implementation of welfare reform after 1996. Two key advantages of the SIPP data are that they permit matching type of insurance coverage to the welfare policy environment in each state in each month, and permit controlling for individual-level fixed effects.
Study Design
We measure how much insurance coverage changed after welfare reform using a difference in differences method that eliminates the influence of time-invariant unobserved individual heterogeneity and of statewide trends in insurance coverage. Models also control for individual, state, and year fixed effects, individual-level characteristics such as education, age, and number of children, plus state-level variables such as real per capita income, real minimum wage, and Medicaid eligibility.
Data Collection/Extraction Methods
We limit our analysis to the SIPP data specific to the month just completed prior to the interview; as a result, we have up to twelve observations for each individual in the SIPP. This paper uses pooled data from the 1992–1996 panels of the SIPP covering the period 1992–1999. Publicly available state identifiers permit the merger of state policies and macroeconomic variables with the SIPP.
Principal Findings
TANF implementation is associated with an 8.1 percent increase in the probability that a welfare-eligible woman was uninsured. Welfare reform had less of an impact on the health insurance coverage of children. For example, TANF implementation was associated with a 3.0 percent increase in the probability that a welfare-eligible child lacked health insurance.
An unintended consequence of welfare reform was to adversely impact the health insurance coverage of economically vulnerable women and children, and that this impact was several times larger than the previous literature implies.
PMCID: PMC1702522  PMID: 16584461
Health insurance; welfare reform; SCHIP; medicaid
22.  Family income and crowd out among children enrolled in Massachusetts Children's Medical Security Plan. 
Health Services Research  2001;36(6 Pt 2):45-63.
OBJECTIVE: To assess whether participation in a state publicly financed health insurance program, Massachusetts Children's Medical Security Plan (CMSP) , which is open to children regardless of income, was associated with disenrollment from private insurance. DATA SOURCES/STUDY DESIGN: A survey of participants in CMSP who were enrolled as of April 1998 was used. We conducted analyses to detect differences in access to and uptake of private insurance between Medicaid-eligible and in eligible children, and between children eligible for the State Children's Health insurance Program (SCHIP) and in eligible children. DATA COLLECTION METHODS: A stratified sample of children was drawn from administrative files. the sampling strategy allowed us to examine crowd out among children based on in come and eligibility for publicly funded coverage: those who were Medicaid-eligible (income pound 133 percent of the federal poverty level [FPL]) , those who were SCHIP-eligible (134-200 percent of FPL) , and those with family in comes that exceed SCHIP eligibility criteria (> 200 percent of FPL). The majority of telephone interviews were conducted with the child's parent/guardian between November 1998 and March 1999. The overall response rate was 61.8 percent , yielding a sample of 996 children. PRINCIPAL FINDINGS: Of the children in our sample whose recent health coverage was employer-sponsored insurance (59 percent), 70 percent were no longer eligible. Few children who had employer-sponsored insurance at enrollment dropped this coverage to enroll in CM SP (1 percent, 4 percent, and 2 percent by income). Compared to Medicaid-eligible children, children with incomes > 133 percent of FPL were significantly more likely to be eligible for employer-sponsored insurance but they were no more likely to have purchased offered coverage. Access to employer-sponsored insurance was limited (19 percent), and uptake was low (13 percent). We found no significant difference between SCHIP-eligible children and those whose family incomes exceeded SCHIP guidelines. CONCLUSIONS: The Massachusetts experience suggests that (1) coverage could be expanded to children with incomes up to 200 percent of FPL with little direct substitution of public coverage for private insurance, and (2) substitution among children with incomes > 200 percent of FPL, who paid a premium that may have restrained crowd out, did not differ from that among SCHIP-eligible children.
PMCID: PMC1383606  PMID: 16148960
23.  Access to Care After Massachusetts’ Health Care Reform: A Safety Net Hospital Patient Survey 
Journal of General Internal Medicine  2012;27(11):1548-1554.
Massachusetts’ health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.
To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.
We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts’ second largest safety net hospital between July 25, 2009 and March 20, 2010.
Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.
Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.
Access to care improved less than access to insurance following Massachusetts’ health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2173-7) contains supplementary material, which is available to authorized users.
PMCID: PMC3475814  PMID: 22825807
access to care; health insurance; health disparities; health care reform; health care policy
24.  Academic Institutionalization of Community Health Services: Way Ahead in Medical Education Reforms 
Policy on medical education has a major bearing on the outcome of health care delivery system. Countries plan and execute development of human resource in health, based on the realistic assessments of health system needs. A closer observation of medical education and its impact on the delivery system in India reveals disturbing trends. Primary care forms backbone of any system for health care delivery. One of the major challenges in India has been chronic deficiency of trained human resource eager to work in primary care setting. Attracting talent and employing skilled workforce seems a distant dream. Talking specifically of the medical education, there are large regional variations, urban - rural divide and issues with financing of the infrastructure. The existing design of medical education is not compatible with the health care delivery system of India. Impact is visible at both qualitative as well as quantitative levels. Medical education and the delivery system are working independent of each other, leading outcomes which are inequitable and unjust. Decades of negligence of medical education regulatory mechanism has allowed cropping of multiple monopolies governed by complex set of conflict of interest. Primary care physicians, supposed to be the community based team leaders stand disfranchised academically and professionally. To undo the distorted trajectory, a paradigm shift is required. In this paper, we propose expansion of ownership in medical education with academic institutionalization of community health services.
PMCID: PMC3893954  PMID: 24478994
Community based medical education; medical education reforms; family medicine
25.  Health Reform and the Constitutionality of the Individual Mandate 
The Patient Protection and Affordable Care Act (ACA) of 2010 is landmark legislation designed to expand access to health care for virtually all legal U.S. residents. A vital but controversial provision of the ACA requires individuals to maintain health insurance coverage or face a tax penalty—the individual mandate. We examine the constitutionality of the individual mandate by analyzing relevant court decisions. A critical issue has been defining the “activities” Congress is authorized to regulate. Some judges determined that the mandate was constitutional because the decision to go without health insurance, that is, to self-insure, is an activity with substantial economic effects within the overall scheme of the ACA. Opponents suggest that Congress overstepped its authority by regulating “inactivity,” that is, compelling people to purchase insurance when they otherwise would not. The U.S. Supreme Court is set to review the issues and the final ruling will shape the effectiveness of health reform.
PMCID: PMC3422862  PMID: 22454219
health reform; Affordable Care Act; Constitution; individual mandate; Commerce Clause; nursing

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