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1.  New evidence on financing equity in China's health care reform - A case study on Gansu province, China 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1472-6963-12-466
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? 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1475-9276-9-23
PMCID: PMC2967551  PMID: 20942899
3.  The Impact of Increasing Health Insurance Coverage on Disparities in Mortality: Health Care Reform in Colombia, 1998–2007 
American journal of public health  2013;103(3):e100-e106.
Objectives
We examined the impact of expanding health insurance coverage on socioeconomic disparities in total and cardiovascular disease mortality from 1998 to 2007 in Colombia.
Methods
We used Poisson regression to analyze data from mortality registries (633 905 deaths) linked to population census data. We used the relative index of inequality to compare disparities in mortality by education between periods of moderate increase (1998–2002) and accelerated increase (2003–2007) in health insurance coverage.
Results
Disparities in mortality by education widened over time. Among men, the relative index of inequality increased from2.59 (95% confidence interval [CI] = 2.52, 2.67) in 1998–2002 to 3.07 (95% CI = 2.99, 3.15) in 2003–2007, and among women, from 2.86 (95% CI = 2.77, 2.95) to 3.12 (95% CI = 3.03, 3.21), respectively. Disparities increased yearly by 11% in men and 4% in women in 1998–2002, whereas they increased by 1% in men per year and remained stable among women in 2003–2007.
Conclusions
Mortality disparities widened significantly less during the period of increased health insurance coverage than the period of no coverage change. Although expanding coverage did not eliminate disparities, it may contribute to curbing future widening of disparities.
doi:10.2105/AJPH.2012.301143
PMCID: PMC3673514  PMID: 23327277
4.  Inequities in access to health care in different health systems: a study in municipalities of central Colombia and north-eastern Brazil 
Introduction
Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia.
Methods
A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need.
Results
There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization.
Conclusions
Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component.
doi:10.1186/1475-9276-13-10
PMCID: PMC3917695  PMID: 24479581
Access to health care; Inequities; Primary health care; Secondary care; Emergency care; Preventive health services; Colombia; Brazil
5.  Reforming the NHS reforms. 
BMJ : British Medical Journal  1994;308(6932):848-849.
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.
PMCID: PMC2540039  PMID: 8167497
6.  Human resources: the Cinderella of health sector reform in Latin America 
Human resources are the most important assets of any health system, and health workforce problems have for decades limited the efficiency and quality of Latin America health systems. World Bank-led reforms aimed at increasing equity, efficiency, quality of care and user satisfaction did not attempt to resolve the human resources problems that had been identified in multiple health sector assessments. However, the two most important reform policies – decentralization and privatization – have had a negative impact on the conditions of employment and prompted opposition from organized professionals and unions. In several countries of the region, the workforce became the most important obstacle to successful reform.
This article is based on fieldwork and a review of the literature. It discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region.
The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. The authors suggest that autochthonous solutions are more likely to succeed than solutions imported from the outside.
doi:10.1186/1478-4491-3-1
PMCID: PMC548503  PMID: 15659241
7.  The Effect of Market Reform on Racial Differences in Hospital Mortality 
Journal of General Internal Medicine  2006;21(11):1198-1202.
OBJECTIVE
To determine whether racial differences in hospital mortality worsened after implementation of a New Jersey law in 1993 that reduced subsidies for uninsured hospital care and changed hospital payment from rate regulation to price competition.
DATA SOURCES/STUDY SETTING
State discharge data for New Jersey and New York from 1990 to 1996.
STUDY DESIGN
We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. Adjusting for patient characteristics, baseline interstate differences, and common intertemporal trends, we compared the effect sizes for whites and blacks in the following 4 groups: overall, uninsured, insured under age 65, and Medicare patients.
DATA COLLECTION/EXTRACTION METHODS
The study sample included 1,357,394 patients admitted to New Jersey or New York hospitals between 1990 to 1996 with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, or acute myocardial infarction (AMI).
PRINCIPAL FINDINGS
The increase in mortality in New Jersey versus New York was significantly larger among blacks than among whites for AMI (2.4% points vs 0.1% points, P-value for difference .026) but not for the other 6 conditions. In groupings of conditions for which hospital admission is non-discretionary and conditions in which admission is discretionary, we found qualitatively larger increases in mortality for blacks but no statistically significant racial differences among patients overall, uninsured patients, insured patients under age 65, or Medicare patients.
CONCLUSIONS
Market-based reform and reductions in subsidies for hospital care for the uninsured in New Jersey were associated with worsening racial disparities in in-hospital mortality for AMI but not for 6 other common conditions.
doi:10.1111/j.1525-1497.2006.00484.x
PMCID: PMC1831664  PMID: 17026731
quality of health care; economics; medical; financing; organized
8.  Costs and coverage. Pressures toward health care reform. 
Western Journal of Medicine  1992;157(5):576-583.
Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.
PMCID: PMC1022049  PMID: 1441510
9.  Access to Care After Massachusetts’ Health Care Reform: A Safety Net Hospital Patient Survey 
Journal of General Internal Medicine  2012;27(11):1548-1554.
ABSTRACT
BACKGROUND
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.
OBJECTIVE
To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.
DESIGN AND PARTICIPANTS
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.
MAIN MEASURES
Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.
KEY RESULTS
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.
CONCLUSIONS
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.
doi:10.1007/s11606-012-2173-7
PMCID: PMC3475814  PMID: 22825807
access to care; health insurance; health disparities; health care reform; health care policy
10.  Primary and managed care. Ingredients for health care reform. 
Western Journal of Medicine  1994;161(1):78-82.
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.
PMCID: PMC1011384  PMID: 7941522
11.  Wisconsin's BadgerCare Plus Reform: Impact on Low-Income Families' Enrollment and Retention in Public Coverage 
Health Services Research  2011;46(1p2):336-347.
Objectives
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.
Conclusions
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.
doi:10.1111/j.1475-6773.2010.01215.x
PMCID: PMC3037786  PMID: 21143476
Medicaid expansions; health care reform; health insurance
12.  Oral Health Care Reform in Finland – aiming to reduce inequity in care provision 
BMC Oral Health  2008;8:3.
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1472-6831-8-3
PMCID: PMC2268684  PMID: 18226197
13.  Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003 
Background
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).
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1472-6963-7-37
PMCID: PMC1828155  PMID: 17335584
14.  Working on reform. How workers' compensation medical care is affected by health care reform. 
Public Health Reports  1996;111(1):12-25.
The medical component of workers' compensation programs-now costing over $24 billion annually-and the rest of the nation's medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers' compensation and traditional health insurance. What is the relationship of the workers' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?
Images
PMCID: PMC1381735  PMID: 8610187
15.  Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? 
Background
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Results
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
Conclusion
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
doi:10.1186/1743-8462-5-24
PMCID: PMC2588611  PMID: 18990236
16.  Trends in Immunization Completion and Disparities in the Context of Health Reforms: The case study of Tanzania 
Background
Of global concern is the decline in under five children mortality which has reversed in some countries in sub Saharan Africa (SSA) since the early 1990 s which could be due to disparities in access to preventive services including immunization. This paper is aimed at determining the trend in disparities in completion of immunization using Tanzania Demographic and Health Surveys (DHS).
Methods
DHS studies randomly selected representative households from all regions in Tanzania since 1980 s, is repeated every five years in the same enumeration areas. The last three data sets (1990, 1996 and 2004) were downloaded and analyzed using STATA 9.0. The analysis included all children of between 12-23 months who would have completed all vaccinations required at 12 months.
Results
Across the time periods 1990, 1996 to 2004/05 the percentage of children completing vaccination was similar (71.0% in 1990, 72.7% in 1996 and 72.3% in 2005). There was no disparity in completion of immunization with wealth strata in 1990 and 1996 (p > 0.05) but not 2004. In 2004/05 there was marked disparity as most poor experienced significant decline in immunization completion while the least poor had significant increase (p < 0.001). All three periods children from households whose head had low education were less likely to complete immunization (p < 0.01).
Conclusion
Equity that existed in 1990 and more pronounced in 1996 regressed to inequity in 2005, thus though at national level immunization coverage did not change, but at sub-group there was significant disparity associated with the changing contexts and reforms. To address sub-group disparities in immunization it is recommended to adopt strategies focused at governance and health system to reach all population groups and most poor.
doi:10.1186/1472-6963-10-299
PMCID: PMC2984499  PMID: 21034497
17.  Reasons Why Patients Remain Uninsured after Massachusetts’ Health Care Reform: A Survey of Patients at a Safety-Net Hospital 
ABSTRACT
BACKGROUND
Following the 2006 Massachusetts health care reform, an estimated 316,492 residents remain uninsured. However, there have been no published studies that examine why Massachusetts residents remain uninsured four years into health reform.
OBJECTIVE
To describe the characteristics of uninsured patients seeking acute medical care in Massachusetts after implementation of health care reform and reasons for lacking insurance.
DESIGN AND PARTICIPANTS
We performed an in-person survey of a convenience sample of patients visiting the emergency department of the state’s second largest safety net hospital between July 25, 2009 and March 20, 2010. We interviewed 431 patients age 18–64, 189 of whom were uninsured.
MAIN MEASURES
Demographic and clinical characteristics, employment and insurance history, reasons for lacking insurance and views of the state’s new “individual mandate”.
KEY RESULTS
The uninsured were largely employed (65.9%), but only a quarter (25.1%) of the employed uninsured had access to employer-sponsored insurance. The majority qualified for subsidized insurance (85.7% earned ≤300% of the federal poverty level), yet many reported being unable to find affordable insurance (32.7%). Over a third (35.2%) were uninsured because they had lost insurance due predominantly to job loss or policy cancellation. For nearly half of the uninsured (48.6%), the individual mandate had motivated them to try to find insurance, but they were unable to find insurance they could afford.
CONCLUSIONS
After full implementation of the Massachusetts health reform, those remaining without insurance are largely the working poor who do not have access to, or cannot afford, either employer sponsored insurance or state subsidized insurance.
doi:10.1007/s11606-011-1868-5
PMCID: PMC3270239  PMID: 21922156
uninsured; health reform; health policy; safety-net institutions; health insurance
18.  Health Care Reform and Concurrent Curative Care for Terminally Ill Children: A Policy Analysis 
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.
doi:10.1097/NJH.0b013e318202e308
PMCID: PMC3401095  PMID: 22822304
concurrent curative care; policy analysis; health care reform; end of life care; children
19.  Health Reform: A Community Experience Using Design Research as a Guide 
Mayo Clinic Proceedings  2011;86(10):973-980.
Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improving individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient’s personal physician coordinating care throughout a patient’s lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery. Mixed methodology provides greater insight into the unexpressed health needs of individuals and into the creation of delivery systems more likely to achieve the triple aim. In a small, midwestern town, a mixed methods approach was used to assess community health needs to facilitate design and implementation of care delivery systems. The research findings suggest that health system design concepts should focus on the creation of health, not health care; foster simplicity; create nurturing relationships; eliminate user fear; and contain costs. These observations can be helpful to health care professionals who are developing new methods of care delivery and policymakers and payers contemplating new payment systems to achieve the goals of the triple aim.
doi:10.4065/mcp.2011.0225
PMCID: PMC3184026  PMID: 21964174
20.  Implementing the IT Infrastructure for Health Reform: Adoption of Health IT among Patient-Centered Medical Home Practices 
While health IT is thought to be critical to the success of new models of care delivery, we know little about the extent to which those pursuing these models are relying on HIT. We studied a large patient-centered medical home (PCMH) demonstration project, a new model of care delivery that has received substantial policy attention, in order to assess which types of HIT were most widely used, and how adoption rates changed over time as PCMH practices matured. We found that clinically-focused HIT tools were both widely adopted, and increasingly adopted, in PCMH practices compared to non-PCMH practices. In contrast, HIT that supports patient-engagement, patient portals and personal health records, was neither in widespread use nor more likely to be adopted over time by PCMH practices compared to other practices. This suggests that these tools may not yet support the types of patient engagement and interactions that PCMH practices seek.
PMCID: PMC3900118  PMID: 24551318
21.  The Dutch health insurance reform: switching between insurers, a comparison between the general population and the chronically ill and disabled 
Background
On 1 January 2006 a number of far-reaching changes in the Dutch health insurance system came into effect. In the new system of managed competition consumer mobility plays an important role. Consumers are free to change their insurer and insurance plan every year. The idea is that consumers who are not satisfied with the premium or quality of care provided will opt for a different insurer. This would force insurers to strive for good prices and quality of care. Internationally, the Dutch changes are under the attention of both policy makers and researchers. Questions answered in this article relate to switching behaviour, reasons for switching, and differences between population categories.
Methods
Postal questionnaires were sent to 1516 members of the Dutch Health Care Consumer Panel and to 3757 members of the National Panel of the Chronically ill and Disabled (NPCD) in April 2006. The questionnaire was returned by 1198 members of the Consumer Panel (response 79%) and by 3211 members of the NPCD (response 86%). Among other things, questions were asked about choices for a health insurer and insurance plan and the reasons for this choice.
Results
Young and healthy people switch insurer more often than elderly or people in bad health. The chronically ill and disabled do not switch less often than the general population when both populations are comparable on age, sex and education.
For the general population, premium is more important than content, while the chronically ill and disabled value content of the insurance package as well. However, quality of care is not important for either group as a reason for switching.
Conclusion
There is increased mobility in the new system for both the general population and the chronically ill and disabled. This however is not based on quality of care. If reasons for switching are unrelated to the quality of care, it is hard to believe that switching influences the quality of care. As yet there are no signs of barriers to switch insurer for the chronically ill and disabled. This however could change in the future and it is therefore important to monitor changes.
doi:10.1186/1472-6963-8-58
PMCID: PMC2287167  PMID: 18366678
22.  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.
doi:10.1377/hlthaff.2011.0321
PMCID: PMC3644505  PMID: 23297270
23.  High-Risk Pools for the Sick and Uninsured Under Health Reform: Too Little and Thus Too Late 
ABSTRACT
Democrats and Republicans have turned to the concept of “high-risk pools” to provide health care for those Americans who face the dual challenge of uninsurance and serious health difficulties. Under the Patient Protection and Affordable Care Act (PPACA), these “high-risk” individuals will receive extensive help and regulatory protections, in concert with a new system of health insurance exchanges. However, these federal provisions do not become operational until 2014. As an interim measure, PPACA provides $5 billion for temporary, federally funded high-risk pools, now known as the Pre-Existing Condition Insurance Plan (PCIP). This analysis explores the adequacy of such funding. Using 2005/06 data from the National Health and Nutrition Examination Survey (NHANES), we find that approximately 4 million uninsured Americans have been diagnosed with emphysema, diabetes, stroke, cancer, congestive heart failure, angina, or a heart attack. To provide adequate health care for uninsured individuals with chronic diseases, the federal PCIP appropriations would need to be many times higher than either Democrats or Republicans have proposed.
doi:10.1007/s11606-010-1490-y
PMCID: PMC3024120  PMID: 20811957
high risk pools; insurance; health reform; patient protection and affordable care act
24.  Healthcare and medical education reforms in India: What lies ahead? 
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.
doi:10.4103/2249-4863.117394
PMCID: PMC3894029  PMID: 24479063
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
25.  Reforms in Pakistan: Decisive Times for Improving Maternal and Child Health 
Healthcare Policy  2012;8(1):24-32.
Pakistan is a struggling economy with poor maternal and child health indicators that have affected attainment of the United Nations Millennium Development Goals 4 and 5 (under-five child and maternal mortality). Recent health reforms have abolished the federal Ministry of Health and devolved administrative and financial powers to the provinces. Ideally, devolution tends to simplify a healthcare system's management structure and ensure more efficient delivery of health services to underserved populations, in this case women and children. In this time of transition, it is appropriate to outline prerequisites for the efficient management of maternal and child health (MCH) services.
This paper examines the six building blocks of health systems in order to improve the utilization of MCH services in rural Pakistan. The targeted outcomes of recent reforms are devolved participatory decision-making regarding distribution of MCH-related services, improved deployment of the healthcare workforce, prioritization of pro-poor strategies for health financing and integration of various health information systems. Given this window of opportunity, the provinces need to guarantee fairness and equity through their stewardship of the healthcare system so as to protect vulnerable mothers and their children, especially in rural, remote and disadvantaged areas of Pakistan.
PMCID: PMC3430152  PMID: 23968601

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