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PubMed1994

Proposal to reimburse occupational medicine disease and injury claims through third party health insurance.

The current system of compensation for the medical costs of occupational illnesses and injuries, a component of health insurance coverage for most workers in the United States, has recently come under scrutiny in the national health care reform debate. The cost of treatment of these conditions is significant, and there exist numerous disincentives for physicians and patients to use the workers' compensation system. Physicians who treat workers with occupationally related diseases may find compensation for a condition is disputed at the same time that it is excluded from payment by third party insurance coverage, leaving the patient selectively uninsured for at least some medical care services. In addition, most workers' compensation programs have been designed in a way that discourages efficient resource use by providers and claimants. We propose allowing health care providers to bill third party health insurers for all care, including work-related diseases and injuries. Insurers, in turn, would bill workers' compensation programs for associated treatment costs. The potential advantages of such a system include reductions in inefficiency and unfair burdens placed on providers and patients, in reporting bias, and in administrative costs balanced against the risks of insurers excluding workers in high risk occupations from obtaining low cost health insurance and shifting away from employers the administrative burden for workers' compensation.

Accidents, Occupational↗
PubMedDate not supplied

Employer coverage of clinical preventive services in the United States.

PURPOSE: To characterize employers' coverage of clinical preventive services. DESIGN: Mercer Human Resource Consulting Inc. included questions on clinical preventive services as part of its National Survey of Employer-Sponsored Health Plans, 2001. SETTING: A national sample of employers of a large, medium, and small number of employees, including governments. SUBJECTS: Respondents self-identified as most knowledgeable about the organization's health benefits. MEASURES: Weighted analyses of responses to eight survey questions on health promotion. RESULTS: The survey was completed by 2180 employers, and the response rate was 21%. More than 90% of employers included increased productivity and decreased health care costs among their most important reasons for coverage of clinical preventive services. Within health insurance, coverage of physical examinations, immunizations, and screenings generally exceeded 50%, but coverage of lifestyle modification services was less than 20%. Only 20% of employers covered tobacco cessation services, and only 4% of employers provided an "optimal" benefit. We compared employers' offerings with a published ranking, by impact and value, of clinical preventive services. We found the biggest discrepancy in tobacco cessation services and alcohol problem prevention, which ranked high in terms of impact and value but are offered by only 20% and 18% of employers, respectively. CONCLUSIONS: Employers seek financial return from their offerings of clinical preventive services to employees, but they are least likely to offer the services most likely to provide this return.

Health Benefit Plans, Employee↗
PubMed1985

Medical care use and expenditure among children and youth in the United States: analysis of a national probability sample.

Good access to health care for all US children and youth remains an important social policy goal. Recent patterns of access as reflected in the presence of regular care sources, health care use, health insurance coverage, and expenditures for medical care are described and analyzed using the subsample of all children 0 to 18 years of age from the 1980 National Medical Care Utilization and Expenditure Survey. Data from the survey indicate that in 1980, 92% of US children and youth had a regular care source and the same percentage were covered for the full year or part of the year by some form of public or private health insurance. However, use rates and patterns of expenditure continued to differ dramatically according to family background factors, particularly race, ethnicity, poverty status, and location of residence. These differences are analyzed and comparative data are presented for groups of children from various sociodemographic groups. Minority-group and near-poor children were found to be at highest risk for limited utilization of services and inadequate insurance coverage.

Adolescent↗
PubMed1996

Congress advances on health care reform: one step at a time.

In adopting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress made a series of small but significant steps toward improving access to health care benefits. The Act's centerpiece is its new requirements for group health plans and for the health insurance industry for assuring portability, access, and renewability of health insurance coverage. Of nearly equal importance is the pilot program established for testing the viability of medical savings accounts. Other health-related changes include adjustments in the rules governing duplication and coordinating of Medicare-related plans, recommendations with respect to privacy of health information of employees, an increase in the deduction for health insurance costs for self-employed individuals, and permission for unemployed persons to make withdrawals from IRAs and other qualified plans for certain medical services' costs. This article summarizes these and other key provisions of HIPAA.

Cost Sharing↗
PubMed1995

The potential impact of health care reform on public health HIV-related activities.

This article observes that, despite the clear potential benefits of health care reform's expanding health insurance coverage for people with human immunodeficiency virus (HIV) disease, there is a real danger of losing existing acquired immunodeficiency syndrome (AIDS) services if federal categorical public health programs are cut. It discusses the considerable accomplishments of the Ryan White CARE Act and of Centers for Disease Control and Prevention (CDC) prevention funding. The funding for these current efforts will not be assumed by near universal insurance coverage for a variety of reasons, including the need to care for populations who are neglected by health care reform, to continue services unlikely to be reimbursable, and to offer care in a range of locations other than licensed health care facilities.

Financing, Government↗
PubMed2003

Bosnian immigrants' perceptions of the United States health care system: a qualitative interview study.

During the 1990s, approximately 300,000 Bosnian immigrants came to the United States as a result of the Balkan wars. In contrast to immigrants from less developed countries, Bosnian refugees were typically older, had experienced significant war related trauma, and were accustomed to universal health insurance coverage. There is little information about Bosnian immigrants' transition to the U.S. health care system. As part of a related project, 12 Bosnian immigrants were interviewed about their perceptions of the U.S. health care system and their experiences as patients. Participants were universally critical of the U.S. system and described several core issues: confusion about insurance coverage, personalized quality of care, access to primary and specialty care; and a perception of U.S. health care as bureaucratic. Participants compared their experience with prewar Bosnian health care along these dimensions. Implications of the findings and suggestions for improving care to the Bosnian immigrant population are provided.

Adult↗
PubMed2001

[Influence of erectile dysfunction on daily life and general attitudes towards treatments].

OBJECTIVES: This study investigates the influence of erectile dysfunction (ED) on daily life and the attitude of citizens toward ED treatments. MATERIALS AND METHODS: A mail survey targeting married males and females, aged 30-79, was conducted throughout the nation. The effective responses were 2,034 males and 1,820 females. RESULTS: The ED prevalence rate of male respondents was 29.9% and that of females (indicating the recognition of husband's ED) was 30.1%. For both males and females, the frequency of sexual intercourse and satisfaction about their sexual lives were significantly lower in respondents with ED. 23.6% of males with ED and 16.0% of females whose husbands have ED experienced a negative influence of their married lives. Among male ED sufferers, however, only 4.8% of them had consulted a physician. The reasons cited most often for not consulting a physician were: "no influence on daily life", "not annoyed by ED", and "no interest in sex", Moreover, the barriers to visiting physicians were frequently cited, such as "shyness", "don't know which hospital to go to", and "expensive". With regard to insurance coverage of ED treatment, 80% or more of both men and women say that "it should be reimbursed for all ED patients" or "it should be conditionally reimbursed". CONCLUSIONS: It becomes clear that ED is found at considerable frequency. However, only 4.8% of ED patients had received appropriate treatment at medical facilities. With regard to insurance coverage for ED treatment, it turned out that 80% or more of both men and women supported reimbursement for ED treatment.

Activities of Daily Living↗
PubMed2003

Medicare program; Medicare prescription drug discount card. Interim final rule with comment period.

Section 101, subpart 4 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, codified in section 1860D-31 of the Social Security Act, provides for a voluntary prescription drug discount card program for Medicare beneficiaries entitled to benefits, or enrolled, under Part A or enrolled under Part B, excluding beneficiaries entitled to medical assistance for outpatient prescription drugs under Medicaid, including section 1115 waiver demonstrations. Eligible beneficiaries may access negotiated prices on prescription drugs by enrolling in drug discount card programs offered by Medicare-endorsed sponsors. Eligible beneficiaries may enroll in the Medicare drug discount card program beginning no later than 6 months after the date of enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and ending December 31, 2005. After December 31, 2005, beneficiaries enrolled in the program may continue to use their drug discount card during a short transition period beginning January 1, 2006 and ending upon the effective date of a beneficiary's outpatient drug coverage under Medicare Part D, but no later than the last day of the initial open enrollment period under Part D. Beneficiaries with incomes no more than 135 percent of the poverty line applicable to their family size who do not have outpatient prescription drug coverage under certain programs--Medicaid, certain health insurance coverage or group health insurance (such as retiree coverage), TRICARE, and Federal employees Health Benefits Program (FEHBP)--also are eligible for transitional assistance, or payment of $600 in 2004 and up to $600 in 2005 of the cost of covered discount card drugs obtained under the program. In most cases, any transitional assistance remaining available to a beneficiary on December 31, 2004 may be rolled over to 2005 and applied toward the cost of covered discount card drugs obtained under the program during 2005. Similarly, in most cases, any transitional assistance remaining available to a beneficiary on December 31, 2005 may be applied toward the cost of covered discount card drugs obtained under the program during the transition period. The Centers for Medicare & Medicaid Services will solicit applications from entities seeking to offer beneficiaries negotiated prices on covered discount card drugs. Those meeting the requirements described in the authorizing statute and this rule, including administration of transitional assistance, will be permitted to offer a Medicare-endorsed drug discount card program to eligible beneficiaries. Endorsed sponsors may charge beneficiaries enrolling in their endorsed programs an annual enrollment fee for 2004 and 2005 of no more than $30; CMS will pay this fee on behalf of enrollees entitled to transitional assistance. To ensure that eligible Medicare beneficiaries take full advantage of the Medicare drug discount card program and make informed choices, CMS will educate beneficiaries about the existence and features of the program and the availability of transitional assistance for certain low-income beneficiaries; and publicize information that will allow Medicare beneficiaries to compare the various Medicare-endorsed drug discount card programs.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2005

Supplemental private health insurance and depressive symptoms in older married couples.

Stress process theory is applied to examine lack of supplemental private health insurance as a risk factor for depressive symptomatology among older married couples covered by Medicare. Dyadic data from 130 African-American couples and 1,429 White couples in the 1993 Asset and Health Dynamics Among the Oldest-Old Survey were analyzed using hierarchical generalized linear modeling. Lack of supplemental insurance is operationalized at the household level in terms of neither spouse covered, one spouse covered, or both spouses covered. Controlling for covariates at both individual and couple levels, supplemental insurance has significant impact on depression, but the pattern differs by race. White couples report the highest depression when neither spouse is covered by private health insurance; African-American couples report the highest depression when only one spouse is covered. Results suggest lack of supplemental private health insurance coverage is a stressor that significantly affects depressive symptoms.

Aged↗
PubMedDate not supplied

Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas.

PURPOSE: Although rates of cancer screening for Latinas are lower than for non-Latina whites, little is known about how insurance status, ethnicity, and nativity interact to influence these disparities. Using a large statewide database, our study examined the relationship between breast and cervical cancer screening rates and socioeconomic and health insurance status among foreign-born Latinas, US-born Latinas, and non-Latina whites in California. METHODS: Data from the1998 California Women's Health Survey (CWHS) were analyzed (n = 3,340) using multiple logistic regression models. Utilization rates of mammography, clinical breast examinations, and Papanicolaou (Pap) smear screening among foreign-born Latinas, US-born Latinas, and non-Latina whites were the outcome measures. RESULTS: Foreign-born Latinas had the highest rates of never receiving mammography, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively) compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors, foreign-born Latinas were more likely to report mammography use in the previous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of health insurance coverage was the strongest independent predictor of low utilization rates for mammography (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.53-2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80-2.90) and Pap smears (OR = 2.89; 95% CI, 2.17-3.85.) CONCLUSIONS: Breast and cervical cancer screening rates vary by ethnicity and nativity, with foreign-born Latinas experiencing the highest rates of never being screened. After accounting for socioeconomic factors, differences by ethnicity and nativity are reversed or eliminated. Lack of health insurance coverage remains the strongest predictor of cancer screening underutilization.

Adolescent↗
PubMed2005

Vulnerability and unmet health care needs. The influence of multiple risk factors.

CONTEXT: Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks. OBJECTIVE: To present a profile of risk factors for poor access based on income, insurance coverage, and having a regular source of care, and examine the association of the profiles with unmet health care needs due to cost. Relationships are examined by race/ethnicity. DESIGN: Analysis of 32,374 adults from the 2000 National Health Interview Survey. MAIN OUTCOME MEASURES: Reported unmet needs due to cost: missing/delaying needed medical care, and delaying obtaining prescriptions, mental health care, or dental care. RESULTS: Controlling for personal demographic and community factors, individuals who were low income, uninsured, and had no regular source of care were more likely to miss or delay needed health care services due to cost. After controlling for these risk factors, whites were more likely than other racial/ethnic groups to report unmet needs. When presented as a risk profile, a clear gradient existed in the likelihood of having an unmet need according to the number of risk factors, regardless of racial/ethnic group. CONCLUSION: Unmet health care needs due to cost increased with higher risk profiles for each racial and ethnic group. Without attention to these co-occurring risk factors for poor access, it is unlikely that substantial reductions in disparities will be made in assuring access to needed health care services among vulnerable populations.

Adult↗
PubMed1995

The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States.

OBJECTIVE: To estimate the prevalence and length of gaps in health insurance coverage and their effect on having a regular source of care in a national sample of preschool-aged children. DESIGN: Follow-up survey of a nationally representative sample of 3-year-old children in the US population by phone or personal interview. PARTICIPANTS: A total of 8129 children whose mothers were interviewed for the 1991 longitudinal Follow-up to the National Maternal and infant Health Survey. MAIN OUTCOME MEASURES: Report of any gap in health insurance for the children, the length of the gap, and the number of different sites where the children were taken for medical care as a measure of continuity of a regular source of care. RESULTS: About one quarter of Us children were without health insurance for at least 1 month during their first 3 years of life. Over half of these children had a health insurance gap of more than 6 months. Less than half of US children had only one site of care during their first 3 years. Children with health insurance gaps of longer than 6 months were at increased risk of having more than one care site (odds ratio = 1.52; 95% confidence interval, 1.19 to 1.96). This risk further increased when an emergency treatment was discounted as a multiple site of care. CONCLUSIONS: Having a gap in health insurance coverage is an important determinant for not having a regular source of care for preschool-aged children. This finding is of concern, given the sizable percentage of children in the United States who lacked continuous health care coverage during a critical period of development.

Child Health Services↗
PubMed2000

Health care and health status and outcomes for patients with type 2 diabetes.

OBJECTIVE: To evaluate access and utilization of medical care, and health status and outcomes that would be influenced by recent medical care, in a representative sample of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A national sample of 733 adults with type 2 diabetes was studied from 1991 to 1994 in the Third National Health and Nutrition Examination Survey. Structured questionnaires and clinical and laboratory assessments were used to determine the frequencies of physician visits, health insurance coverage, screening for diabetes complications, treatment for hyperglycemia, hypertension, and dyslipidemia; and the proportion of patients who met treatment goals and established criteria for health outcome measures including hyperglycemia, albuminuria, obesity, hypertension, and dyslipidemia. RESULTS: Almost all patients had 1 source of primary care (95%), 2 or more physician visits during the past year (88%), and health insurance coverage (91%). Most (76%) were treated with insulin or oral agents for their diabetes, and 45% of those patients taking insulin monitored their blood glucose at least once per day The patients were frequently screened for retinopathy (52%), hypertension (88%), and dyslipidemia (84%). Of those patients with hypertension, 83% were diagnosed and treated with antihypertensive agents and only 17% were undiagnosed or untreated; most of the patients known to have dyslipidemia were treated with medication or diet (89%). Health status and outcomes were less than optimal: 58% had HbA1c >7.0, 45% had BMI >30, 28% had microalbuminuria, and 8% had clinical proteinuria. Of those patients known to have hypertension and dyslipidemia, 60% were not controlled to accepted levels. In addition, 22% of patients smoked cigarettes, 26% had to be hospitalized during the previous year, and 42% assessed their health status as fair or poor. CONCLUSIONS: Rates of health care access and utilization, screening for diabetes complications, and treatment of hyperglycemia, hypertension, and dyslipidemia in type 2 diabetes are high; however, health status and outcomes are unsatisfactory. There are likely to be multiple reasons for this discordance, including intractability of diabetes to current therapies, patient self-care practices, physician medical care practices, and characteristics of U.S. health care systems.

Adult↗
PubMed2001

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE Dental Program. Office of the Secretary, DoD. Final rule.

On October 23, 2000 (65 FR 63202), the Department of Defense published a final rule on TRICARE Family Member Dental Plan. The rule had an effective date that began during the Presidential Moratium on Rules, therefore, this rule is republished to change the effective date to April 1, 2001. This rule is published exactly as previously published. No changes have been made. It revises the comprehensive CHAMPUS regulation pertaining to the Expanded Active Duty Dependents Benefit Plan, or more commonly referred to as the TRICARE Family Member Dental Plan (TFMDP). The TFMDP limited eligibility to eligible dependents of active duty members (under a call or order that does not specify a period of thirty (30) day or less). Concurrent with the timeframe of the publication of the proposed rule, the Defense Authorization Act for Fiscal Year 2000 (Pub. L. 106-65, sec. 711) was signed into law and its provisions have been incorporated into this final rule. The Act authorized a new plan, titled the TRICARE dental program (TDP), which allows the Secretary of Defense to offer a comprehensive premium based indemnity dental insurance coverage plan to eligible dependents of active duty members (under a call or order that does not specify a period of thirty (30) days or less), eligible dependents of members of the Selected Reserve and Individual Ready Reserve, and eligible members of the Selected Reserve and Individual Ready Reserve. The Act also struck section 1076b (Selected Reserve dental insurance), or Chapter 55 of title 10, United States Code, since the affected population and the authority for that particular dental insurance plan has been incorporated in 10 U.S.C. 1076a. Consistent with the proposed rule and the provisions of the Defense Authorization Act for Fiscal Year 2000, the final rule places the responsibility for TDP enrollment and a large portion of the appeals program on the dental plan contractor; allows the dental plan contractor to bill beneficiaries for plan premiums in certain circumstances; reduces the former TFMDP enrollment period from twenty-four (24) to twelve (12) months; excludes Reserve component members ordered to active duty in support of a contingency operation from the mandatory twelve (12) month enrollment; clarifies dental plan requirements for different beneficiary populations; simplifies enrollment types and exceptions; reduces cost-shares for certain enlisted grades; adds anesthesia as a covered benefit; provides clarification on the Department-s use of the Congressional waiver for surviving dependents; incorporates legislative authority for calculating the method by which premiums may be raised and allowing premium reductions for certain enlisted grades; and reduces administrative burden by reducing redundant language, referencing language appearing in other CFR sections and removing language more appropriate to the actual contract. These improvements will provide Uniformed Service members and families with numerous quality of life benefits that will improve participation in the plan, significantly reduce enrollment errors and positively effect utilization of this important dental plan. The proposed rule was titled the --TRICARE Family Member Dental Plan.

Government Agencies↗
PubMed2004

Compliance with recommendations for follow-up care in Latinos: the Los Angeles Latino Eye Study.

PURPOSE: To determine rates of follow-up eye and health care in the Los Angeles Latino Eye Study (LALES), a population-based sample of Latinos. METHODS: Participants received a complete ophthalmic examination and were referred to a local healthcare provider for follow-up care, if ocular or systemic disease was found. Participants receiving referrals were later contacted by telephone and interviewed in their language of choice (English or Spanish) by a trained bilingual interviewer, to determine follow-up rates, and to discuss the barriers preventing follow-up care. RESULTS: Of 430 referred participants, 335 (78%) completed the follow-up survey; 278 (68%) of the responders obtained follow-up care. Among the 108 (32%) individuals who did not seek follow-up care, 54 (50%) cited cost of care as the main reason, while 30 (28%) indicated a lack of knowledge as to where to go for care, and 18 (17%) indicated the unavailability of health care. Logistic regression analyses (controlling for acculturation, co-morbid conditions, and patients' prior knowledge of their diagnoses) revealed that participants with insurance coverage, diagnosis with a systemic disease, and higher educational level were more likely to have received follow-up care. CONCLUSION: More than two thirds of the participants reported seeking the recommended follow-up care. Although cost, availability of services, and convenience of accessing care were found to be major barriers to obtaining health care, higher education, insurance coverage, and prior knowledge of the disease, were associated with receiving recommended care. Knowledge of barriers to seeking health care is important when developing community based healthcare programs directed toward the Latino population.

Acculturation↗
PubMed1997

Use of health care services by persons with panic symptoms.

OBJECTIVE: Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic. METHODS: This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage. RESULTS: Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services. CONCLUSIONS: Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.

Adolescent↗
PubMed2003

The impact of patient education and psychosocial supports on return to normalcy 36 months post-kidney transplant.

INTRODUCTION: Improvements in immunosuppression, and expansion of immunosuppression coverage by Medicare now necessitate beginning to define success in transplantation from a holistic or whole person approach rather than the historical emphasis on patient and graft survival alone. In a new transplant environment, efforts will have to be made to redefine practice so that kidney transplant recipients are prepared for 10 or more years of life with a transplanted graft. Currently, 83% of transplanted patients will never return to work. The purpose of this study is to determine how targeted education and specific psychosocial supports affect the transplant patient's return to normalcy 36 months after kidney transplant. Normalcy is defined as age and socially appropriate activities for that patient. METHODS: This is a synopsis of a 1-year cross-sectional study of 51 patients who received kidney transplants in 1999 at or near their 36-month anniversary date. Thirty-six months was chosen because this is the date when most patients will lose their Medicare coverage for immunosuppression. In 1999, a multidisciplinary plan was initiated to restructure the transplant recipient evaluation process, such that education about kidney transplantation and expectations for return to normalcy were addressed at the initial 'introduction to transplant session'. These measures were then consistently reinforced with each subsequent contact. At the second contact, written verbal plans for medication purchase and return to normalcy were identified. The team made a conscious effort to develop relationships with the recipients and their significant others, with the intention to better empower them to return to normalcy post-transplant. These measures (education and psychosocial support) were this study's independent variables. At 36 months, all patients were contacted by telephone and a 12-item questionnaire was administered. The questionnaire sought information about the study's dependent variables - employment and insurance status, pre- and post-transplant. RESULTS: In this study, 44% of pre-transplant patients were non-disabled compared with 62% of transplanted patients at 36 months post-transplant (P = 0.06, Chi square). Non-disabled includes persons who are employed, homemakers, students, retired or otherwise involved in age and socio-economically appropriate activities. Pre-transplant, 23% of recipients utilized Medicare and Medicaid for health insurance coverage. At 36 months post-transplant, only 11 or 20% of patients were dependent on Medicare and Medicaid. Pre-transplant, 17 recipients had private insurance coverage vs. 23 patients 36 months later (P < 0.02, Chi square). Fifty-six per cent of the patients received a living donor transplant. CONCLUSION: A targeted multidisciplinary programme of education and psychosocial support that emphasizes return to normalcy and non-disability, beginning with the first exposure to transplant and continuing throughout the first 6 months post-transplant, yielded high rates of return to normalcy for kidney transplant recipients.

Convalescence↗
PubMed1997

Federalism and health system reform. Prospects for state action.

OBJECTIVE: To assess the prospect that the states, acting independently, would undertake health insurance coverage expansions that together would result in meaningful reductions in the extent of uninsurance nationally. DESIGN: We use microsimulation methods to contrast the federal income tax payments needed to finance a national program covering the uninsured with the state income tax payments needed to finance a state-specific program for the same purpose. The contrast reveals the effects on the tax burdens of differences among states in uninsured rates and tax capacity. SETTING: Continental United States. PATIENTS OR OTHER PARTICIPANTS: Observations from the 1990 through 1993 Current Population Survey (N =305 477 families), weighted to represent the population of each state. INTERVENTION: Illustrative public health insurance program for families with incomes below 250% of poverty, not covered by current public or employer-sponsored health insurance. MAIN OUTCOME MEASURES: Change in percent uninsured, change in per capita total tax payments. RESULTS: The per capita cost of a state-specific program is directly related to current uninsured rates, $130 in states with low uninsured rates (10%) to $230 in states with high uninsured rates (21%). This would represent increases in state total tax effort of 10% to 19%, respectively. In contrast, equal tax effort to finance a national program would imply per capita yields of about $200 in the low-uninsured states and about $150 in the high-uninsured states. CONCLUSIONS: Substantial state tax effort would be necessary to cover the low-income uninsured-especially in states with the highest uninsured rates, which also have the lowest tax capacity. Targeted federal financial assistance may be necessary, if policymakers wish to induce many states to provide health insurance coverage for their uninsured.

Health Care Reform↗