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1.  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
2.  Private Hospital Sector Development: An Exploratory Study on Providers Perspective in Addis Ababa, Ethiopia 
Ethiopian Journal of Health Sciences  2011;21(Suppl 1):59-64.
Over the past decade there is a trend of fast development in the private hospital sector in Ethiopia. This important component of the health care system has received policy attention and federal government is a promoter for private health care. Yet lack of basic data on the factors affecting the growth of private health care provision in the country and no studies are available on this issue in Ethiopia. The aim of this study is to get some preliminary insights on the factors affecting the growth and development of private hospital sector in Addis Ababa, Ethiopia with perspective of provider.
A hospital based qualitative study was conducted in 25 for-profit hospitals in Addis Ababa using key informant in-depth interviews and secondary data was collected from Federal Ministry of Health and Addis Ababa City Health Administration and private hospital providers.
The findings of the study suggest that private hospital sector is expanding significantly in recent years in Ethiopia. The active role of government is a catalyst for the growth of private facilities in the country. Factors outside the health are growing disposable income, improvements in literacy, road networks, population growth and long standing diseases, all contribute to the trend. But private providers are facing many problems, like availability of trained manpower, escalation of costs, availability and quality of drugs and financing mechanisms.
Private hospital sector is expanding in Ethiopia. But private providers are vulnerable to imperfections in the existing market structure. Government and professional bodies need to make a concerted effort to address these issues and design appropriate strategies to promote and regulate this sector effectively.
PMCID: PMC3275879  PMID: 22435009
Private hospital sector; Development; Providers
3.  A Review of Literature to Understand the Complexity of Equity, Ethics and Management for Achieving Public Health Goals in India 
In the context of inadequate public spending on health care in India (0.9% of the GDP); government liberalized its policies in the form of subsidized lands and tax incentives, resulting in the mushrooming of private hospitals and clinics in India. Paradoxically, a robust framework was not developed for the regulation of these health care providers, resulting in disorganized health sector, inadequate financing models, and lack of prioritization of services, as well as a sub-optimal achievement of the Millennium Development Goals (MDG). We systematically reviewed the evidence base regarding regulation of private hospitals, applicability of private-public mix, state of health insurance and effective policy development for India, while seeking lessons on regulation of private health systems, from South African (a developing country) and Australian (a developed country) health care systems.
PMCID: PMC3972518
Private health sector; Child; Ethics; Survival; Health regulation; Health policies
4.  The uninsured and patient dumping: recent policy responses in indigent care. 
This article discusses the uninsured population and the phenomenon known as "patient dumping"--the transfer of a patient from one hospital (typically a private hospital) to a public hospital because of the patient's lack of insurance or inability to pay. The uninsured are the most vulnerable to patient dumping. The growth of patient dumping, a profile of the uninsured who are most likely to be a minority, and an analysis of federal and state policy responses to patient dumping are all discussed. The need for reform of the American health care system is highlighted and the Canadian health system is suggested as an alternative model.
PMCID: PMC2571592  PMID: 1800761
5.  A Legislative Agenda for Health: 1987 to 1992 
Health policy issues in the 1980s have been influenced largely by fewer federal dollars and by the increasing prominence of the private sector. As a result, several indicators of health status, especially among the poor, have deteriorated. The 1986 election and the return of Democratic Party control of the US Congress provides opportunities to seek to restore and increase funding in several areas and to develop new policy initiatives. Recommendations for funding and new health policy initiatives in the areas of AIDS, maternal and child health, substance abuse, health manpower development, long-term care for the elderly, biomedical research, and national health insurance are presented. In addition, the importance of improving the general level of education and employment is stressed, as they have an impact upon health status.
PMCID: PMC2625570  PMID: 3334061
6.  Designing health insurance information for the Medicare beneficiary: a policy synthesis. 
Health Services Research  1988;23(5):685-720.
Can Medicare beneficiaries make rational and informed decisions about their coverage under the Medicare program? Recent policy developments in the Medicare program have been based on the theory of competition in medical care. One of the key assumptions of the competitive model is the free flow of adequate information, enabling the consumer to make an informed choice from among the various sellers of a particular product. Options for Medicare beneficiaries in supplementing their basic Medicare coverage include the purchase of private supplementary insurance policies or enrollment in a Medicare HMO. These consumers, in a complex health insurance market, have only limited information available to them because many health plans do not make adequate comparable product information available. Moreover, since the introduction of the Medicare HMO option, the long-range plan for management of the Medicare budget has become based on the large-scale voluntary enrollment of beneficiaries into capitated health plans. The policy instrument that has been used to improve beneficiary decisions on how to supplement Medicare coverage is the informational or educational program. This synthesis presents findings regarding the relative effectiveness of different types of health insurance information programs for the Medicare beneficiary in an effort to promote practical use of the most effective types of information.
PMCID: PMC1065532  PMID: 3060450
7.  California Hospitals’ Response to State and Federal Policies Related to Health Care–Associated Infections 
In October 2008, the Centers for Medicare and Medicaid Services (CMS) denied payment for ten selected health care–associated infections (HAI). In January 2009, California enacted mandatory reporting of infection prevention processes and HAI rates. This longitudinal mixed-methods study examined the impact of federal and state policy changes on California hospitals. Data on structures, processes, and outcomes of care were collected pre- and post-policy changes. In-depth interviews with hospital personnel were performed after policy implementation. More than 200 hospitals participated with 25 personnel interviewed. We found significant increases in adoption of and adherence to evidence-based practices and decreased HAI rates (p < .05). Infection preventionists (IP) spent more time on surveillance and in their offices and less time on education and in other locations (p < .05). Qualitative data confirmed mandatory reporting had intended and unintended consequences and highlighted the importance of technology and organizational climate in preventing infections and the changing IPs’ role. This is especially relevant because the California Department of Public Health has since mandated hospitals to report data on 29 different for surgical site infections and a lawsuit has been filed to delay the implementation of these requirements.
PMCID: PMC3220599  PMID: 22042613
state legislation; patient safety; nursing/health care workforce issues; health care quality; federal legislation
8.  The changing profile of the urban uninsured: Exploring implications of rise in the number of moderate-income uninsureds 
Access to care is a major problem in urban America that increasingly affects new segments of the population. Although the demographic profile of the uninsured has changed, recording large increases in numbers of moderate-income uninsured persons, it has not been accompanied by changes in health care safety net programs or increased availability of private insurance products tailored to these groups. Any such changes, however, need to be based on a good understanding of the similarities and differences between low-income and moderate-income uninsured. Based on a telephone survey of the uninsured in three northern New Jersey counties, this study presents a systematic comparison of low-income (below 150% of federal poverty level) and moderate-income (150% to 350% federal poverty level) uninsured on attitudes to health care, perceptions regarding access to care, health status, and health care utilization. We discuss the implications of this comparison for expanding health care access and design of safety net programs and institutions.
PMCID: PMC3456142  PMID: 15047792
Health care access; Health care utilization; Urban uninsured; Safety net programs
9.  An analysis of trends and determinants of health insurance and healthcare utilisation in the Russian population between 2000 and 2004: the 'inverse care law' in action 
The break-up of the USSR brought considerable disruption to health services in Russia. The uptake of compulsory health insurance rose rapidly after its introduction in 1993. However, by 2000 coverage was still incomplete, especially amongst the disadvantaged. By this time, however, the state health service had become more stable, and the private sector was growing. This paper describes subsequent trends and determinants of healthcare insurance coverage in Russia, and its relationship with health service utilisation, as well as the role of the private sector.
Data were from the Russia Longitudinal Monitoring Survey, an annual household panel survey (2000–4) from 38 centres across the Russian Federation. Annual trends in insurance coverage were measured (2000–4). Cross-sectional multivariate analyses of the determinants of health insurance and its relationship with health care utilisation were performed in working-age people (18–59 years) using 2004 data.
Between 2000 and 2004, coverage by the compulsory insurance scheme increased from 88% to 94% of adults; however 10% of working-age men remained uninsured. Compulsory health insurance coverage was lower amongst the poor, unemployed, unhealthy and people outside the main cities. The uninsured were less likely to seek medical help for new health problems. 3% of respondents had supplementary (private) insurance, and rising utilisation of private healthcare was greatest amongst the more educated and wealthy.
Despite high population insurance coverage, a multiply disadvantaged uninsured minority remains, with low utilisation of health services. Universal insurance could therefore increase access, and potentially contribute to reducing avoidable healthcare-related mortality. Meanwhile, the socioeconomically advantaged are turning increasingly to a growing private sector.
PMCID: PMC2684531  PMID: 19397799
10.  Public Finance Policy Strategies to Increase Access to Preconception Care 
Maternal and Child Health Journal  2006;10(Suppl 1):85-91.
Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. Millions of women of childbearing age (15–44) lack adequate health coverage (i.e., uninsured or underinsured), and others live in medically underserved areas. Service delivery fragmentation and lack of professional guidelines are additional barriers. This paper reviews barriers and opportunities for financing preconception care, based on a review and analysis of state and federal policies. We describe states’ experiences with and opportunities to improve health coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children's Health Insurance Program (SCHIP). The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.
PMCID: PMC1592251  PMID: 16802188
Finance; Policy; Maternal health; Infant health; Preconception; Medicaid; Title V; Family planning
11.  Toward a More Reliable Federal Survey for Tracking Health Insurance Coverage and Access 
Health Services Research  2006;41(3 Pt 1):918-945.
Examination of the extent to which federal surveys provide the data needed to estimate the coverage/cost impacts of policy alternatives to address the problem of uninsurance.
Data Sources/Study Setting
Assessment of the major federal household surveys that regularly provide information on health insurance and access to care based on an examination of each survey instrument and related survey documentation and the methodological literature.
Study Design
Identification of the data needed to address key policy questions on insurance coverage, assessment of how well existing surveys meet this need, definition of the critical elements of an ideal survey, and examination of the potential for building on existing surveys.
Data Collection/Extraction Methods
Collection and critical assessment of pertinent survey documentation and methodological studies.
Principal Findings
While all the federal surveys examined provide valuable information, the information available to guide key policy decisions still has major gaps. Issues include measurement of insurance coverage and critical content gaps, inadequate sample sizes to support precise state and substate estimates, considerable delays between data collection and availability, and concerns about response rates and item nonresponse. Our assessment is that the Current Population Survey (CPS) and the National Health Interview Survey could be most readily modified to address these issues.
The vast resources devoted to health care and the magnitude of the uninsurance problem make it critical that we have a reliable source for tracking health care and coverage at the national and state levels and for major local areas. It is plausible that this could be more cost effectively done by building on existing surveys than by designing and fielding a new one, but further research is needed to make a definitive judgment. At a minimum, the health insurance information collected on the CPS should be revised to address existing measurement problems.
PMCID: PMC1713213  PMID: 16704520
Health insurance coverage; uninsured rates; estimates and measurement of health insurance coverage
12.  Assessing barriers to health insurance and threats to equity in comparative perspective: The Health Insurance Access Database 
Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments.
The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990–2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments.
These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems’ performance with regards to health insurance access and equity.
This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.
PMCID: PMC3393626  PMID: 22551599
13.  The geographic distribution of private health insurance in Australia in 2001 
Private health insurance has been a major focus of Commonwealth Government health policy for the last decade. Over this period, the Howard government introduced a number of policy changes which impacted on the take up of private health insurance. The most expensive of these was the introduction of the private health insurance rebate in 1997, which had an estimated cost of $3 billion per annum.
This article uses information on the geographic distribution of the population with private health insurance cover to identify associations between rates of private health insurance cover and socioeconomic status. The geographic analysis is repeated with survey data on expenditure on private health insurance, to provide an estimate of the rebate flowing to different socioeconomic groups.
The analysis highlights the strong association between high rates of private health insurance cover and high socioeconomic status and shows the substantial transfer of funds, under the private health insurance rebate, to those living in areas of highest socioeconomic status, compared with those in areas of lower socioeconomic status, and in particular those in the most disadvantaged areas. The article also provides estimates of private health insurance cover by federal electorate, emphasising the substantial gaps in cover between Liberal Party and Australian Labor Party seats.
The article concludes by discussing implications of the uneven distribution of private health insurance cover across Australia for policy formation. In particular, the study shows that the prevalence of private health insurance is unevenly distributed across Australia, with marked differences in prevalence in rural and urban areas, and substantial differences by socioeconomic status. Policy formation needs to take this into account. Evaluating the potential impact of changes in private health insurance requires more nuanced consideration than has been implied in the rhetoric about private health insurance over the last decade.
PMCID: PMC3224949  PMID: 19686590
14.  An Economic History of Medicare Part C 
The Milbank quarterly  2011;89(2):289-332.
Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector.
In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program’s structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period.
Beneficiaries’ access to private plans has been inconsistent over the program’s history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years.
Major changes in Medicare Advantage’s payment rules are needed in order to simultaneously encourage the participation of private plan, the provision of high-quality care, and to save Medicare money.
PMCID: PMC3117270  PMID: 21676024
Medicare; managed care; health care costs
15.  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?
PMCID: PMC1381735  PMID: 8610187
16.  Reconsidering the effect of Medicaid on health care services use. 
Health Services Research  1996;30(6):791-808.
OBJECTIVE: Our research compares health care use by Medicaid beneficiaries with that of the uninsured and the privately insured to measure the program's effect on access to care. DATA SOURCES/STUDY SETTING: Data include the 1987 National Medical Expenditure Survey and the Survey of Income and Program Participation for 1984-1988. STUDY DESIGN: We predict annual use of ambulatory care and inpatient hospital care for Medicaid beneficiaries receiving AFDC cash assistance and compare it to what their use would be if uninsured or if covered by private insurance. Comparisons are based on multivariate models of health care use that control for demographic and economic characteristics and for health status. Our model distinguishes among Medicaid beneficiaries on the basis of eligibility to account for the poor health of beneficiaries in some eligibility groups. PRINCIPAL FINDINGS: AFDC Medicaid beneficiaries use considerably more ambulatory care and inpatient care than they would if they remained uninsured. Use among the AFDC Medicaid population is about the same as use among otherwise similar, privately insured persons. Use rates differ substantially among different Medicaid beneficiary groups, supporting the expectation that some beneficiary groups are in poor health. CONCLUSIONS: Although Medicaid has increased access to health care services for beneficiaries to rates now comparable to those for the privately insured population, because of lower cost sharing in Medicaid we would expect higher service use than we are finding. This suggests possible barriers to Medicaid patients in receiving the care they demand. Enrollment of less healthy individuals into some Medicaid beneficiary groups suggests that pooled purchasing arrangements that include Medicaid populations must be designed to ensure adequate access for the at-risk populations and, at the same time, to ensure that private employers do not opt out because of high community-rated premiums.
PMCID: PMC1070093  PMID: 8591930
17.  Public Systems Policy and the Private Marketplace 
Public systems policy has been inadequate in terms of setting directions and regulations to govern the design, development and implementation of health and hospital information systems. No federal or local government group and no private body has policy making authority -- or responsibility -- in any clearly defined and coordinated way. One effect of this dearth of public policy has been a wasteful, repetitive development of basic applications, constantly repeating activities already undertaken by others. Another result is that policy for health and hospital information systems has developed in a most haphazard fashion; principal factors influencing it have been private initiatives of individuals and associations, individual determinations of major medical centers and universities, and profit-motivated systems development by commercial sector hardware and software houses. If health systems are to move forward in the 80s in accordance with the potential of current technology, then there is a need for a new consortium of the public and private sector, in which government, private academic and not-for-profit groups, and private commercial organizations will all make their appropriate contribution to a consistent public systems policy.
PMCID: PMC2203820
18.  Medigap Premiums and Medicare HMO Enrollment 
Health Services Research  2002;37(6):1445-1468.
Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans.
Data Sources
The analysis is based on a sample of Medicare beneficiaries drawn from the 1996–1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration).
Study Design
Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums.
Principal Findings
We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points.
This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies.
PMCID: PMC1464046  PMID: 12546281
Medigap; Medicare managed care; premium effect on enrollment decisions; HMOs; Medicare
19.  Health care models guiding mental health policy in Kenya 1965 - 1997 
Mental health policy is needed to set the strategy and direction for the provision of mental health services in a country. Policy formulation does not occur in a vacuum, however, but is influenced by local and international factors in the health sector and other sectors.
This study was carried out in 1997 to examine the evolution of mental health policy in Kenya between 1965 and 1997 in the context of changing international concepts of health and development. Qualitative content analysis of policy documents was combined with interviews of key policy makers.
The study showed that during the period 1965-1997 the generic health policy in Kenya changed from one based on the Medical Model in the 1960s and 1970s to one based on the Primary Health Care Model in the late 1970s and the 1980s and finally to one based on the Market Model of health care in the 1990s. The mental health policy, on the other hand, evolved from one based on the Medical Model in the 1960s to one based on the Primary Health Care Model in the 1990s, but did not embrace the Market Model of health care. This resulted in a situation in the 1990s where the mental health policy was rooted in a different conceptual model from that of the generic health policy under which it was supposed to be implemented. This "Model Muddlement" may have impeded the implementation of the mental health policy in Kenya.
Integration of the national mental health policy with the general health policy and other sector policies would be appropriate and is now underway.
PMCID: PMC2872652  PMID: 20426855
20.  Julie Rovner’s Health Care Policy and Politics A to Z: a review 
Drawing on her vast experience covering health care policy on Capitol Hill, Julie Rovner has written explanations for over 300 key concepts that demystify the world of United States Government health care policy. In the newest edition of Health Care Policy and Politics A to Z, readers will find updated information on long-term health care spending, abortion, Medicaid and Medicare, health insurance and the uninsured, and the State Children’s Health Insurance Program (SCHIP). New entries reflect important changes in recent years and include the Medicare Modernization Act, abstinence education, electronic health records, health savings accounts, and Project BioShield. The book does have its gaps, especially as it relates to mental health. However, this book should become a standard reference for all health care professionals.
PMCID: PMC3270918  PMID: 22312221
public health; health care policy; United States; public health law; United States
21.  Medical Home Disparities for Children by Insurance Type and State of Residence 
Maternal and child health journal  2012;16(Suppl 1):S178-S187.
The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children’s Health, estimating the prevalence of parents’ report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33–63 % and 57–76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public–private difference: 5–34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents’ report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.
PMCID: PMC3444255  PMID: 22453328
Medical home; Public insurance; Disparities; Health policy; National Survey of Children’s Health
22.  The Association between Health Insurance Coverage and Diabetes Care; Data from the 2000 Behavioral Risk Factor Surveillance System 
Health Services Research  2005;40(2):361-372.
To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States.
Data Source
The 2000 Behavioral Risk Factor Surveillance System.
Study Design
Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use.
Principal Findings
Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance.
Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.
PMCID: PMC1361145  PMID: 15762896
Quality of care; health insurance; diabetes
23.  Integrated primary health care in Australia 
To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities.
Description of policy
Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care.
Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.
PMCID: PMC2787230  PMID: 19956377
primary health care; health policy; integration; Australia
24.  Quality and Innovations for Caring Hospitalized Older Persons in the Unites States 
Aging and Disease  2013;5(1):41-51.
Older persons are occasionally acutely ill and their hospitalizations frequently end up with complications and adverse outcomes. Medicare from U.S. federal government’s payment resource for older persons is facing financial strain. Medicare highlights both cost-saving and high quality of care while older persons are hospitalized. Several health policy changes were initiated to achieve Medicare’s goals. In response to Medicare’s health policy changes, U.S. hospital environments have been changed and these resulted in hospital quality measurements’ improvement. American seniors are facing the challenges during and around their hospital care. Several innovative measures are suggested to overcome these challenges.
PMCID: PMC3901613  PMID: 24490116
Elderly; Health policy; Health services; Health care quality; Hospitalization
25.  An analysis of actions to promote health in underprivileged urban areas: a case in Brazil 
BMC Family Practice  2013;14:80.
Two policies stood out in the 2000s geared towards changing the care model adopted in Brazil: The National Policy on Primary Health Care, based on a family health care model, and the National Policy on Health Promotion.
The aim of this study was to analyze health promotion actions developed by family health care teams in the municipality of Belford Roxo. This town was chosen by virtue of its “below average” level of primary health care services offered in relation to other municipalities in Rio de Janeiro state.
The following methodological strategies were employed: analysis of health systems, document analysis (2010 Annual Health Schedule and 2010 Annual Management Report), participant observation and interviews with nine health care professionals in the region of study, namely: the manager of the Regional Health Polyclinic (responsible for health care actions in the region), and nurses belonging to the eight family health teams. Giddens’ Theory of Structuration was used for analysis of the results.
Varying levels of health care activity were found, indicating that the managers have been either unable or lacked the commitment to perform the proposed actions. From a structural point of view, 87.5% of the teams were incomplete. Also of particular note was the lack of any physicians in the teams, which, despite its detrimental effect, was regarded by the interviewees as “natural”.
Strong political party influence in the area hindered relations between the team and the local population. Health education, especially through lectures was the main health promotion activity picked up in this study.
No cross-sectorial or public participation actions were identified. Connections between the teams for sharing responsibilities were found to be very weak.
In addition to political factors, there are also structural limitations such as a lack of human resources that overburdens the teams’ daily activities. From this point of view, the political context and lack of professionals were restrictive factors for health promotion.
Belford Roxo is not necessarily representative of other experiences in Brazil. However, problems such as patronage, political manipulation, poverty and incipient cross-sectorial actions are common to other Brazilian towns and cities.
PMCID: PMC3683323  PMID: 23758615
Primary health care; Family health strategy; Health promotion; Health policy

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