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.
The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.
As the United States embarks on the most ambitious national health reform since the 1960s, this article highlights the challenges faced by behavioral health agencies, providers, and clients in rural areas and presents recommendations to improve access to and quality of services. Lessons learned from five years of research on a major systems-change initiative in New Mexico illuminate potential problem areas for rural agencies under national health reform, including insufficient financial resources, shortages of trained staff, particularly clinicians with advanced credentials, and delays in adopting the latest information technology. We recommend that rural states: (1) undertake careful planning for smooth transitions; (2) provide financial resources and technical assistance to expand rural safety-net services and capacity; (3) modify the health home model for the rural context; and (4) engage in ongoing evaluation, which can help ensure the early identification and rectification of unanticipated implementation issues.
Medicaid; rural health services; mental health; health reform; United States
To examine the effect of premiums and benefits on the health plan choices of older enrollees who choose Federal Employees Health Benefits Program (FEHBP) health plans as their primary payer.
Administrative enrollment data from the Office of Personnel Management (OPM) and plan premiums and benefits data taken from the Checkbook Guide to health plans.
We estimate individual plan choice models where the choice of health plan is a function of out-of-pocket premium, actuarial value, plan attributes, and individual characteristics. Plan attributes include plan structure (fee-for-service/preferred provider organization, point-of-service, or health maintenance organization), drug benefit structure, and whether or not the plan covers other types of spending such as dental services and diabetic supplies. The models are estimated by conditional logit. Our study focuses on three populations that currently choose FEHBP as their primary health care coverage and are similar to the Medicare population: current employees and retirees who are approaching the age of Medicare eligibility (ages 60–64) and current federal employees age 65+. Current employees age 65+ are eligible for Medicare, but their FEHBP plan is their primary payer. Retirees and employees 60–64 are not yet eligible for Medicare but are similar in many respects to recently age-eligible Medicare beneficiaries. We also estimate our model for current employees age 55 and younger as a comparison group.
Data Collection Methods
We select a random sample of retirees and employees age 60–64, as well as all current employees age 65+, from the OPM administrative database for the calendar year 2001. The plan choices available to each person are determined by the plans participating in their metropolitan statistical area. We match plan premium and attribute information from the Checkbook Guide to each plan in the enrollee's list of choices.
We find that current workers 65+, 60–64, and non-Medicare eligible retirees are sensitive to variation in plan premiums. The premium elasticities for these groups are similar in magnitude to those of the age 55 and under employee group. Older workers and retirees not yet eligible for Medicare are willing to pay a substantial amount for plans with open provider networks. The willingness to pay for open networks is significantly greater for these groups than for younger employees. Willingness to pay for open network plans varies significantly by income, but varies little by age within group.
Our finding that older workers and non-Medicare eligible retirees are sensitive to plan premiums suggests that choice-based reform of Medicare would lead to cost-conscious choices by Medicare beneficiaries. However, our finding that these groups are willing to pay more for open network plans than younger employees suggest that higher risk individuals may migrate toward higher benefit, higher cost plans. Our findings on the relationship between income and willingness to pay for open network plans suggest that means testing is a viable reform for lowering Medicare program costs.
Medicare; health insurance; health plan choice
Preparing long term reformatory plan for the health system, like other macro plans, requires guiding principles which is according to the values, and as a bridge, connect the ideals and values to the goals. This study was designed with the purpose of explaining the values and principles of health system, and as a pre-requisite to compilation of Iran’s health system reform plan at 2025.
The document of values and principles of health system reform plan for 2025 was developed by reviewing the literature and receiving the opinions of senior experts of health system, and was criticized in focus group discussion sessions of experts and decision makers.
The values of Iran are: dignity of human, the right to maximum attainable level of health, comprehensive health, equity and social cohesion. The principles of this health system include: institutionalizing the ethical values, responsiveness and accountability, equitable access (utilization), prevention and health promotion, community participation, inter-sectoral collaboration, integrated stewardship, benefit from innovation and desired technology, human resources promotion and excellence and harmony.
Based on the perception of cultural and religious teachings in Iran, protecting of human dignity and human prosperity are the ultimate social goal. In this sense, health and healthy humans, in its holistic concept (physical, mental, social health and spiritual) are the center and development in any form should lead to the human prosperity in a way that each of the individuals could enjoy the maximum attainable level of health in its holistic meaning and in a faire manner.
Health system; Value; Principle; Iran
The Patient Protection and Affordable Care Act (PPACA) aims to provide affordable health insurance and expanded health care coverage for some 32 million Americans. The PPACA makes provisions for using technology, evidence-based treatments, and integrated, patient-centered care to modernize the delivery of health care services. These changes are designed to ensure effectiveness, efficiency, and cost-savings within the health care system.
To gauge the addiction treatment field’s readiness for health reform, the authors developed a Health Reform Readiness Index (HRRI) survey for addiction treatment agencies. Addiction treatment administrators and providers from around the United States completed the survey located on the http://www.niatx.net website. Respondents self-assessed their agencies based on 13 conditions pertinent to health reform readiness, and received a confidential score and instant feedback.
On a scale of “Needs to Begin,” “Early Stages,” “On the Way,” and “Advanced,” the mean scores for respondents (n = 276) ranked in the Early Stages of health reform preparation for 11 of 13 conditions. Of greater concern was that organizations with budgets of < $5 million (n = 193) were less likely than those with budgets > $5 million to have information technology (patient records, patient health technology, and administrative information technology), evidence-based treatments, quality management systems, a continuum of care, or a board of directors informed about PPACA.
The findings of the HRRI indicate that the addiction field, and in particular smaller organizations, have much to do to prepare for a future environment that has greater expectations for information technology use, a credentialed workforce, accountability for patient care, and an integrated continuum of care.
Health care reform; Addiction treatment; Substance use disorder treatment; SUD; Behavioral health; Organizational change; Care delivery; Health reform readiness index
The Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision-making processes. To facilitate changes seen as necessary but politically difficult, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives. The question raised here is whether this has had any effect on the speed of restructuring of the hospital sector.
The empirical part is a case study of the restructuring process in Innlandet Hospital Trust (IHT), which was one of the largest enterprise established after the hospital reform and where the vision for restructuring was clearly set. Different sources of qualitative data are used in the analysis. These include interviews with key actors, observational data and document studies.
The analysis demonstrates how the new professional leaders at first acted in accordance with the intentions of the hospital reform, but soon chose to avoid the more ambitious plans for restructuring the hospital structure and in fact reintroduced local politics into the decision-making process. The analysis further illustrates how local networks and engagement of political representatives from all levels of government complicated the decision-making process surrounding local structural reforms. Local political representatives teamed up with other actors and created powerful networks. At the same time, national politicians had incentives to involve themselves in the processes as supporters of the status quo.
Because of the incentives that faced political actors and the controversial nature of major hospital reforms, the removal of local politicians and the centralization of ownership did not necessarily facilitate reforms in the hospital structure. Keeping politics at an arm's length may simply be unrealistic and further complicate the politics of local hospital reforms.
The government of Morocco approved two reforms in 2005 to expand health insurance coverage. The first is a payroll-based mandatory health insurance plan for public-and formal private–sector employees to extend coverage from the current 16 percent of the population to 30 percent. The second creates a publicly financed fund to cover services for the poor. Both reforms aim to improve access to high-quality care and reduce disparities in access and financing between income groups and between rural and urban dwellers. In this paper we analyze these reforms: the pre-reform debate, benefits covered, financing, administration, and oversight. We also examine prospects and future challenges for implementing the reforms.
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.
Health insurance; Coronary artery disease; Revascularisation procedures; Health policy
To assess accessibility and affordability of health care in eight countries of the former Soviet Union.
Data Sources/Study Setting
Primary data collection conducted in 2010 in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine.
Cross-sectional household survey using multistage stratified random sampling.
Data Collection/Extraction Methods
Data were collected using standardized questionnaires with subjects aged 18+ on demographic, socioeconomic, and health care access characteristics. Descriptive and multivariate regression analyses were used.
Almost half of respondents who had a health problem in the previous month which they viewed as needing care had not sought care. Respondents significantly less likely to seek care included those living in Armenia, Georgia, or Ukraine, in rural areas, aged 35–49, with a poor household economic situation, and high alcohol consumption. Cost was most often cited as the reason for not seeking health care. Most respondents who did obtain care made out-of-pocket payments, with median amounts varying from $13 in Belarus to $100 in Azerbaijan.
Access to health care and within-country inequalities appear to have improved over the past decade. However, considerable problems remain, including out-of-pocket payments and unaffordability despite efforts to improve financial protection.
Access; former Soviet Union; health systems; equity; out-of-pocket payments
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.
Equity; Chinese health care reform; Financing; Kakwani index
Rather than improving efficiency, the reforms imposed on the NHS have increased bureaucracy, reduced patient choice, limited the range of core services, and led to inequity of treatment. In this paper I examine how the medical profession might help to solve these problems. Priorities must be set for health care since no government can afford all the possibilities offered by medical science. It is essential to forge a consensus of patients, carers, professionals, the public, and government if a system of priorities is to be equitable and just. We also need to be able to measure quality of outcome in health care. This requires consensus on what is the desired outcome and the development of appropriate guidelines, audit, and performance review. This is primarily a task for the health professions supported by management and by adequate investment. Basically, the government must reinstate the three traditional values of the NHS--equity, consensus, and regard for representative professional advice.
This special issue addresses the legacy of the United States Public Health Service Syphilis Study on health reform, particularly the Affordable Care Act (ACA). The 12 manuscripts cover the history and current practices of ethical abuses affecting American Indians, Latinos, Asian Americans and African Americans in the United States and in one case, internationally. Commentaries and essays include the voice of a daughter of one of the study participants in which we learn of the stigma and maltreatment some of the families experienced and how the study has impacted generations within the families. Consideration is given in one essay to utilizing narrative storytelling with the families to help promote healing.
This article provides the reader a roadmap to the themes that emerged from the collection of articles. These themes include population versus individual consent issues, need for better government oversight in research and health care, the need for overhauling our bioethics training to develop a population level, culturally driven approach to research bioethics. The articles challenge and inform us that some of our assumptions about how the consent process best works to protect racial/ethnic minorities may be merely assumptions and not proven facts. Articles challenge the belief that low participation rates seen in biomedical studies have resulted from the legacy of the USPHS Syphilis Study rather than a confluence of factors rooted in racism, bias and negative treatment. Articles in this special issue challenge the “cultural paranoia” of mistrust and provide insights into how the distrust may serve to lengthen rather than shorten the lives of racial/ethnic minorities who have been used as guinea pigs on more than one occasion. We hope that the guidance offered on the importance of developing a new framework to bioethics can be integrated into the foundation of health care reform.
Tuskegee; research bioethics; survivors
Can traces of rapid socio-economic changes within a society be reflected in experimental games? The post-Mao reforms in China provide a unique natural quasi-experiment to study people from the same society who were raised with radically different values about distribution of wealth and altruistic behavior. We tested whether the size of offers in the ultimatum and dictator games are an increasing function of the number of years Chinese citizens experienced of the Mao era (“planned economy”). For the cohort that lived throughout the entire Mao era, we found that mean offers in the two games were substantially higher than what is typically offered in laboratory studies. These offers were also higher than those of two younger Chinese cohorts. In general, the amount offered decreased with less time spent under Mao, while in the oldest group in which every member spent the same amount of time under Mao, the younger members tended to offer more, suggesting an additional effect of early education under Mao and contradicting the alternative hypothesis that generosity increases with age. These results suggest that some of the observed individual differences in the offers made in experimental games can be traced back to the values of the socio-economic era in which individuals grew up.
In this review, we summarize and review reforms to the mental health service in the United Kingdom from 1999 to the present. Our analysis is based on government documents describing the reforms and providing guidelines for their implementation. In addition, we summarize prospective studies of psychosis from the first episode and early treatment studies on the basis of existing systematic reviews. The UK mental health reforms have attracted major government funding and have been used to commission specialized (“functional”) community teams for people with severe mental illness. The reforms include changes to services for first-episode psychosis, which have attracted considerable consumer support. The UK service reforms are continuing, with the aim of providing services fit for the 21st century.
mental health services; health care reform; Great Britain; national health programs; schizophrenia
To examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997.
We used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics.
Six disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics.
There were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased.
The shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use.
Postacute care; skilled nursing facility; rehabilitation; home health care; Balanced Budget Act
The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements.
School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs’ impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths’ academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation’s youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.
Within the Patient Protection and Affordable Care Act of 2010 or health care reform, is a relatively small provision about concurrent curative care that significantly affects terminally ill children. Effective on March 23, 2010, terminally ill children, who are enrolled in a Medicaid or state Children’s Health Insurance Plans (CHIP) hospice benefit, may concurrently receive curative care related to their terminal health condition. The purpose of this article was to conduct a policy analysis of the concurrent curative care legislation by examining the intended goals of the policy to improve access to care and enhance quality of end of life care for terminally ill children. In addition, the policy analysis explored the political feasibility of implementing concurrent curative care at the state-level. Based on this policy analysis, the federal policy of concurrent curative care for children would generally achieve its intended goals. However, important policy omissions focus attention on the need for further federal end of life care legislation for children. These findings have implications nurses.
concurrent curative care; policy analysis; health care reform; end of life care; children
This research uses data from a longitudinal study to examine how two provisions in the Patient Protection and Affordable Care Act could affect health insurance coverage among young women who have aged out of foster care. It also explores how allowing young people to remain in foster care until age twenty-one affects their health insurance coverage, use of family planning services, and information about birth control. We find that young women are more likely to have health insurance if they remain in foster care until their twenty-first birthday and that having health insurance is associated with an increase in the likelihood of receiving family planning services. Our results also suggest that many young women who would otherwise lack health insurance after aging out of foster care will be eligible for Medicaid under the health care reform law. Because having health insurance is associated with use of family planning services, this increase in Medicaid eligibility may result in fewer unintended pregnancies among this high-risk population.
McDonough’s perspective on healthcare reform in the US provides a clear, coherent analysis of the mix of access and delivery reforms in the Affordable Care Act (ACA) aka Obamacare. As noted by McDonough, this major reform bill is designed to expand access for health coverage that includes both prevention and treatment benefits among uninsured Americans. Additionally, this legislation includes several financial strategies (e.g. incentives and penalties) to improve care coordination and quality in the hospital and outpatient settings while also reducing healthcare spending and costs. This commentary is intended to discuss this mix of access and delivery reform in terms of its potential to achieve the Triple Aim: population health, quality, and costs. Final remarks will include the role of the US federal government to reform the American private health industry together with that of an informed consume
US Healthcare Reform; Obamacare; Affordable Care Act (ACA); Healthcare Exchanges; Triple Aim
Prior to January 1, 1997, individuals with drug- or alcohol-related disabilities could qualify for federal public assistance through the Supplemental Security Income (SSI) program. During the welfare reforms of the Clinton administration, this policy was changed resulting in lost income and health care benefits for many low-income substance abusers. This paper examines the historical underpinnings to the elimination of drug addiction and alcoholism (DA&A) as qualifying impairments for SSI disability payments. Following this, empirical evidence is presented on the effect this policy change had on the subsequent economic security of former SSI DA&A beneficiaries. Findings indicate that study participants that lost SSI benefits suffered increased economic hardship following the policy change. These findings have important implications for future social welfare policymaking decisions.
Welfare reform; Supplemental Security Income; substance abuse; economic security
The Patient Protection and Affordable Care Act (ACA), more commonly known as health reform, is designed to expand health coverage to 32 million uninsured Americans by 2019 and makes significant changes to public and private health insurance systems that will affect providers of HIV care. We review the major features of the legislation and when they will be implemented, discuss the ways in which it will affect HIV care for different patient populations, and outline implementation challenges that are relevant for HIV care. We conclude with ways in which HIV providers can get involved to learn more about the law and help their patients take advantage of the new opportunities for health coverage.
Affordable Care Act; health insurance coverage; Medicaid; Medicare; Ryan White HIV/AIDS Program
To analyze the effects of health reform efforts in two large states—New York and Massachusetts.
Data Sources/Study Setting
National Health Interview Survey (NHIS) data from 1999 to 2008.
We take advantage of the “natural experiments” that occurred in New York and Massachusetts to compare health insurance coverage and health care access and use for adults before and after the implementation of the health policy changes. To control for underlying trends not related to the reform initiatives, we subtract changes in the outcomes over the same time period for comparison groups of adults who were not affected by the policy changes using a differences-in-differences framework. The analyses are conducted using multiple comparison groups and different time periods as a check on the robustness of the findings.
Data Collection/Extraction Methods
Nonelderly adults ages 19–64 in the NHIS.
We find evidence of the success of the initiatives in New York and Massachusetts at expanding insurance coverage, with the greatest gains reported by the initiative that was broadest in scope—the Massachusetts push toward universal coverage. There is no evidence of improvements in access to care in New York, reflecting the small gains in coverage under that state's reform effort and the narrow focus of the initiative. In contrast, there were significant gains in access to care in Massachusetts, where the impact on insurance coverage was greater and a more comprehensive set of reforms were implemented to improve access to a full array of health care services. The estimated gains in coverage and access to care reported here for Massachusetts were achieved in the early period under health reform, before the state's reform initiative was fully implemented.
Comprehensive reform initiatives are more successful at addressing gaps in coverage and access to care than are narrower efforts, highlighting the potential gains under national health reform. Tracking the implications of national health reform will be challenging, as sample sizes and content in existing national surveys are not currently sufficient for in-depth evaluations of the impacts of reform within many states.
Health reform; uninsurance; public coverage; employer-sponsored insurance coverage; crowd-out; health care access and use
Since India became a republic in 1951, there has been steady progress on all fronts of human and economic development. India has matured as the largest democracy in the world and and also earned the reputation of being one of the fastest growing economies during last two decades. However, the country remains challenged with several pressing issues which includes maintaining good health for second largest population in world. As a signatory of Alma Ata declaration, provision of primary health care has remained a priority area in the planning process. Although the targets of “Health for all by 2000” were missed, several programs are under implementation targeted towards achieving MDGs (Millennium Development Goals). Recent years shall be marked as very eventful from the perspective of health care reforms in India. For the first time a basic framework for Universal Health Coverage (UHC) has been proposed. A brief review of the programs and policies rolled out recently, provides us an insight into the future direction of the dynamic health system of India.
Clinical Establishment Act; Family Medicine; Health care reforms; Indian Public Health Standards; NABH; National Health Mission; New AIIMS Institutions; Medical Education Reforms; Twelfth five year plan; Universal Health Coverage; UCPMP