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PubMed1997

Equity and adequacy in school funding.

Since 1971, most states have been subject to lawsuits seeking to reform their education funding systems. These cases are litigated on the basis of state (not federal) constitutional language and generally seek either greater equity in funding among school districts or a guaranteed level of adequate funding for education. State supreme courts have found the finance systems unconstitutional in 16 states, and many states are still actively involved in litigation. Even where litigation has not occurred or has not succeeded, the prospect of litigation has prompted revisions of state funding policies. Despite the predominant role equity and adequacy play in litigation, there are no universally accepted definitions for either of these words in education funding. Most commonly, equity is measured in terms of the variation in per-pupil revenues among school districts in a single state. By this measure, some states have greater funding equity than others, and in most states wealthy districts have significantly higher per-pupil expenditures than do poor districts. Equity is likely to be greater when the residents of poor districts pay higher taxes. (In some states, residents in poorer areas pay twice as much of their income in local taxes as do residents of wealthier communities.) Equity is also greater in those states where the state's share of the education budget is higher and where the state consistently targets its contributions to lower-income districts. Much of current litigation and legislative activity in education funding seeks to assure "adequacy," that is, a sufficient level of funding to deliver an adequate education to every student in the state. Most states have not explicitly addressed the questions of how much education is "adequate" or how educational standards can be converted to a finance formula. Several approaches to calculating the cost of an adequate education are described.

Adolescent↗
PubMed2002

Pegvisomant. Pharmacia.

Pegvisomant, a polyethylene glycol (PEG) derivative of human growth hormone (GH) that acts as a highly selective GH receptor antagonist, is under development by Pharmacia (formerly Sensus) as a potential treatment for acromegaly. By February 2001, Sensus had submitted an NDA for the treatment of acromegaly, and an approvable letter indicating outstanding issues had been received by July 2001. Pegvisomant was granted Orphan Drug status by the FDA and was designated for Priority Review. Pegvisomant also received Orphan Drug designation in the EU and Japan. In March 2001, additional regulatory filings were being planned for later in 2001. In October 2001, Pharmacia was preparing an NDA in Japan for the treatment of acromegaly. By September 1998, phase 1 trials of the treatment were underway for diabetic retinopathy, and were planned for diabetic nephropathy in 1999. By September 1997, a phase II trial to test the effects of pegvisonant an insulin sensitivity and secretion in type II diabetes patients was underway. However, no development has been reported for these indications since the dates given. By 1994, Sensus had licensed technology for development of GH receptor antagonists from Genentech and Ohio University. Sensus was to pay Genentech, and Genentech was to receive equity in Sensus and royalties from the commercialization of any product resulting from the agreement. In April 2000, the company entered into a licensing agreement with Shearwater Polymers for the PEGylation of pegvisomant using Shearwater's proprietary technology, which is now used to produce the 20-kDa PEG-derivative of pegvisomant. In June 1999, Pharmacia Corp (formerly Pharmacia & Upjohn) signed an agreement to purchase 19.9% of Sensus and to potentially acquire the remainder of the company at a later date. In March 2001, Pharmacia completed its purchase of Sensus. Analysts at Merrill Lynch predicted in February 2002 that the product would be launched in 2003, with US revenues of $20 million, rising to $115 million in 2006.

Animals↗
PubMed2005

Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia.

This article presents research findings into the effectiveness of an innovative equity fund approach to improving access to public sector health services for the poor in Kirivong Operational Health District in Cambodia. The operational health district is the lowest organizational level in the Cambodian health system, providing services through health centres and a single referral hospital. An equity fund involves a third party identifying the poor and paying user fees on their behalf by reimbursing the service provider, thus relieving health staff of such responsibility. We explore the appropriateness of utilizing community members to identify the poorest. The impact of newly introduced pagoda-managed equity funds on access to public health services for the poorest, and on their out-of-pocket expenditure during illness episodes, is then examined. We conclude with an evaluation of the contribution of the equity funds to community participation. The research indicates that identification by community members of those eligible for equity funds is feasible, accrues minimal direct costs, and is effective. Households identified as eligible for equity fund benefits were poorer than those identified as non-beneficiaries. Direct costs associated with seeking care were considerably lower for equity fund beneficiaries than for non-beneficiaries, and fewer beneficiaries than non-beneficiaries initially consulted the private sector, providing evidence of the equity fund's ability to attract the poorest to the public sector. The level and nature of community participation was enhanced considerably following the introduction of the pagoda-managed equity funds. In order to maximize and sustain the equity benefits of such funds, we recommend that external agencies (such as international non-governmental organizations) limit their role to the provision of technical support and advice, rather than taking the lead on implementation and administration. Facilitating the design, implementation, administration and management of equity funds by indigenous community-based organizations has the advantage of not only greatly reducing administrative costs, allowing a large proportion of the fund to be spent on services for the poor, but also of enhancing local ownership, thus increasing the likelihood of equity funds being sustained in the future.

Adolescent↗
PubMed2004

Poor smokers, poor quitters, and cigarette tax regressivity.

The traditional view that excise taxes are regressive has been challenged. I document the history of the term regressive tax, show that traditional definitions have always found cigarette taxes to be regressive, and illustrate the implications of the greater price responsiveness observed among the poor. I explain the different definitions of tax burden: accounting, welfare-based willingness to pay, and welfare-based time inconsistent. Progressivity (equity across income groups) is sensitive to the way in which tax burden is assessed. Analysis of horizontal equity (fairness within a given income group) shows that cigarette taxes heavily burden poor smokers who do not quit, no matter how tax burden is assessed.

Financing, Personal↗
PubMed2004

Inequalities in purchase of mosquito nets and willingness to pay for insecticide-treated nets in Nigeria: challenges for malaria control interventions.

OBJECTIVE: To explore the equity implications of insecticide-treated nets (ITN) distribution programmes that are based on user charges. METHODS: A questionnaire was used to collect information on previous purchase of untreated nets and hypothetical willingness to pay (WTP) for ITNs from a random sample of householders. A second survey was conducted one month later to collect information on actual purchases of ITNs. An economic status index was used for characterizing inequity. MAJOR FINDINGS: The lower economic status quintiles were less likely to have previously purchased untreated nets and also had a lower hypothetical and actual WTP for ITNs. CONCLUSION: ITN distribution programmes need to take account of the diversity in WTP for ITNs if they are to ensure equity in access to the nets. This could form part of the overall poverty reduction strategy.

Animals↗
PubMed2000

Lead abatement training for underserved populations: lessons learned.

An environmental-justice (equity) grant program was used to make accessible an existing lead-training program to minority persons and residents of low-income communities. The purpose of the program was to enhance the knowledge base within the communities concerning lead hazards and intervention strategies and expand possibilities for employment in the lead abatement industry. Barriers to attendance were anticipated and addressed, and included transportation, meals, license application fees, reminders of course date and location, and day care. The program was evaluated through measures of recruitment rates, pre- and post-testing scores, and change in perception of confidence at pre-test, post-test, and at four-month follow-up. Fee-paying registrants over the same time period were used as a comparison group. First day attendance rates for individuals recruited into the equity-grant was 59 percent, of these 94 percent completed all days. Equity and fee-paying groups had similar scores on the pre-test (p = .209), while mean scores on the final exam differed significantly (p < .001) between the groups and were 77 percent and 85 percent, respectively. After adjusting for demographic and course type attended, perceptions of self-efficacy (benefit) and outcome-effectiveness (confidence) increased significantly from pre- to post-tests for both groups and remained at post-course levels at four months follow-up. Lessons learned include: (1) Lead abatement and other related activities can be successfully taught through traditional training methods; (2) A necessary element for delivery of educational services to minority groups is forming workable ties with local community groups, but eligibility requirements must be maintained; (3) Once barriers to first-day attendance are overcome, the information necessary to perform specific work skills can be taught; (4) Positive changes in belief are not dependent on minority status, income, or education levels; (5) Training and education increased confidence in ability to perform learned skills, and belief that there will be a beneficial outcome when performed for themselves, their families, and communities; and, (6) A consensus regarding applicability of regulations must be achieved among federal, state, and local communities.

Adult↗
PubMedDate not supplied

Assessing progressivity of out-of-pocket payment: with illustration to Malaysia.

Throughout the world, policy makers are considering or implementing financing strategies that are likely to have a substantial impact on the equity of health financing. The assessment of the equity implication is clearly important, given the potential impact that alternative finance sources have on households. Households incur out-of-pocket payment directly from their budget, apart from their public or private insurance. Out-of-pocket payment is the primary concern, given their undesirable impact on households. Progressivity measures departures from proportionality in the relationship between out-of-pocket payment and ability to pay. It is the most frequently used yardstick to assess the equity of out-of-pocket payments in empirical studies. This paper provides an evaluation of such progressivity measures, undertaken using four approaches (proportion approach, tabulation approach, concentration curve and Kakwani's index), in order to reveal their usefulness and underlying notion. It is illustrated empirically with data on out-of-pocket payment for health care in Malaysia for 1998/ 1999, based on the nationally representative Household Expenditure Survey. Results indicate that out-of-pocket payments are mildly progressive, whilst the four approaches have their benefits and limitations in assessing equity implications. This analysis is of interest from a policy perspective, given Malaysia's heavy reliance on out-of-pocket payments to finance health care.

Cost Sharing↗
PubMed1992

Financing health services in Sub-Saharan Africa: options for decision makers during adjustment.

The financing of health services has become an increasingly critical and urgent issue in many developing countries particularly in Sub-Saharan Africa. This paper analyses options available to policy makers. The possible effects and side effects of strategies are described based on the experience from different countries. The dangers of simplistic solutions are discussed. A cautious approach is recommended taking into consideration the lessons learned in other regions accompanied by a careful ongoing evaluation especially regarding the ability to pay of the poorer sections of the population. Providing for equity in health care should be an important guiding principle. It therefore appears to be necessary to find an appropriate mix of public and private sector interventions with elements of cost-sharing for services and drugs, insurance schemes and more efficient use of available resources.

Africa↗
PubMed2004

Sex differences in first-year students at Canadian medical schools.

OBJECTIVES: To compare male and female medical students by age, level of education before admission to medical school, race/ethnicity, parental education level, socioeconomic status, and attitudes toward public health care. METHODS: In 2001, we conducted an Internet-based survey of all students enrolled in the 16 medical schools across Canada. Based on the high response rate, first-year medical students at Canadian medical schools outside of Quebec were included in this analysis. The interactions between sex and age, years of premedical education, race/ethnicity, parental occupation, education and household income, impact of finances on choice of medical school, future specialty and practice location, attitudes toward private funding in the Canadian health care system were examined using descriptive statistics and chi2 tests. RESULTS: There were no significant differences between male and female medical students in age, level of education before admission, and race/ethnicity. Female students' fathers (p=.046) and mothers (p=.061) were more likely to hold positions of higher occupational status than were those of male students. There was no significant difference between the parental household incomes of male and female students. Male students were more likely than female students to state that financial considerations would affect their choice of specialty (p=.002) and practice location (p=.002). Male students were more likely to express a positive attitude toward private funding in the health care system, both with respect to increasing the amount of private funding (p=.007) and the addition of private paying patients (p=.002). CONCLUSION: Although women have almost reached equity with men in undergraduate medical education, female students are more likely than male students to have highly educated parents, suggesting that some barriers to access may still exist. The differences in attitudes of female and male medical students to finances and the public health care system become increasingly important as more women practice medicine. These sex differences need to be investigated further, as they could have implications for health policy.

Adult↗
PubMed2025

Covering medical care costs for participants in the eMERGE Network: Challenges for equity and implementation.

PURPOSE: To investigate the complexities of covering study-recommended medical care costs for individuals (in order to prevent lack of adherence due to financial reasons), which have received little attention. METHODS: We explored the deliberations, decisions, and challenges faced by the Electronic Medical Records and Genomics (eMERGE) Network during the implementation of a genomic research project recommending clinical care based on high-risk results defined largely by polygenic risk scores. Two surveys were disseminated to eMERGE sites: to identify preferences about payment for specific care recommendations (survey 1) and to understand the operational processes of covering medical care costs (survey 2). RESULTS: Paying for a subset of care recommendations for the funded study duration was identified as the most feasible approach for covering medical care costs for participants who received high-risk genomic results. Each eMERGE site, by necessity, used diverse approaches to pay for medical care costs. CONCLUSION: eMERGE researchers balanced competing concerns about bias, equity, study design, regulatory compliance, and cost in designing a unified approach to cover some of the recommended medical care costs in the study. Many implementation challenges were encountered. Findings can inform researchers and regulatory bodies about the implications and complications of covering medical care costs in translational research studies focused on prevention.

Humans↗
PubMed1997

The poor pay more: health-related inequality in Thailand.

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/ insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.

Financing, Personal↗
PubMed1992

Gender and the relationship between perceived fairness of pay or promotion and job satisfaction.

Brockner and Adsit (1986) found that satisfaction with an exchange relationship was more strongly related to perceptions of equity among men than women. Kahn (1972) reported that men were more likely than women to distribute outcomes to individuals in direct proportion to their input. We evaluated potential gender differences among 12,979 personnel in 30 different organizational systems in (a) correlations between fairness and job satisfaction scores and (b) standardized group differences in the perceived amounts of pay and promotion fairness and expressed levels of facet and global job satisfaction. The fairness-satisfaction relationship was not higher for men, and there were no practical differences in fairness perceptions and job satisfaction between men and women.

Career Mobility↗
PubMed1991

Medicare payment options for recombinant erythropoietin therapy.

We analyzed alternative payment approaches that Medicare could use to pay for recombinant human erythropoietin (rHuEPO) therapy. How Medicare pays for rHuEPO therapy will affect whether providers make prudent purchases of the biologic and prescribe it appropriately and whether companies offer the program low prices. Medicare's policies may also guide policies of other third parties. Selecting payment options for Medicare payment requires balancing desirable and undesirable implications, especially trade-offs between improving access to and quality of care for beneficiaries versus constraining costs to Medicare and its beneficiaries. The options for paying providers that contain financial incentives to constrain expenditures also contain incentives for providers to skimp on use, perhaps to the detriment of patients' quality of care. On the other hand, options that may reward additional use may lead to higher expenditures and threaten the quality of care from the direction of overuse. Medicare currently varies the level and method of payment for rHuEPO therapy according to the setting in which it is provided. Equity among beneficiaries and providers and incentives for efficient use of medical services would argue for paying the same amount for the same service, regardless of where it was provided. Whatever payment options are adopted, the Health Care Financing Administration (HCFA) will have to be able to exercise flexibility in monitoring and responding to changing market conditions. In this dynamic market, the number of manufacturers, medical indications for use approved by the Food and Drug Administration, and, eventually, Medicare's predominance are likely to evolve over time. The appropriate level and perhaps even the method of payment may well change with market conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Competitive Bidding↗
PubMed1986

AIDS: the risks to insurers, the threat to equity.

The AIDS crisis poses a special challenge for American health care, which depends heavily on private insurance to pay medical bills. Can we provide adequate health care to all who need it and still meet the financial requirements of the private health insurance industry? More insurance carriers are turning to antibody testing in order to eliminate poor risks from non-group, direct-pay pools. Some cost-conscious employers have attempted to fire AIDS patients summarily or to exclude AIDS coverage from group insurance policies. Various remedies are available for spreading the financial risks of the epidemic, such as covering persons with AIDS under Medicare or in state-sponsored health insurance pools. Ethical questions about cost and access may also rekindle the debate about the need for national health insurance.

AIDS-Related Complex↗
PubMed2000

Analytic dimensions of a prescription-medication benefit in medicare.

BACKGROUND: Many analysts believe that the lack of coverage for outpatient prescription medications represents a conspicuous deficiency in the Medicare benefits package. OBJECTIVE: This paper uses insurance theory to design and estimate the costs of a Medicare catastrophic-medication outpatient benefit. RESULTS: For efficiency and equity purposes, and to accommodate the tradeoff between the cost to the federal government and the insurance value of such a benefit to Medicare enrollees, we favor a benefit that would be means-tested by employing deductibles, coinsurance rates, and catastrophic limits, all of which would be progressively graduated for 7 household income classes. For equity reasons, we propose that the government's share of the medication benefit be financed from the general tax fund, using the progressive income tax. Another source of potential savings within the Medicare program that could pay for a medication benefit would be elimination of fraud, waste, and abuse. CONCLUSIONS: Because our proposal addresses both the efficiency and equity dimensions of a Medicare outpatient medication benefit, we believe it is worthy of serious consideration by both policymakers and Congress.

Aged↗
PubMed1982

Medicare program; interest charges on overpayments and underpayments to providers and suppliers of services--Health Care Financing Administration. Final rule with comment period.

These regulations implement section 117 of Pub. L. 97-248, the Tax Equity and Fiscal Responsibility Act of 1982, and establish specific rules for assessing and paying interest on overpayments and underpayments to providers and suppliers of Medicare services. These changes make HCFA regulations consistent with existing rules issued by the General Accounting Office (GAO) and the Department of Justice under the Federal Claims Collection Act, and should encourage providers and suppliers of services to repay debts more promptly.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2004

Executive pay trends and golden parachute tax: a collision on the horizon.

Ironically, many corporations will likely discover that tying equity-based executive compensation more closely to performance will cost millions of dollars when there is a merger or acquisition. The reason: Internal Revenue Code Section 280G, which is designed to discourage "excess" parachute payments, often assesses a significantly higher toll on performance-based compensation than on time-vested equity payments. There is no magic remedy, but advance planning can often help mitigate the impact. This article describes the dilemma and suggests several approaches to the challenge.

Accounting↗
PubMedDate not supplied

[Gender, equality, and health services access: an empirical approximation].

This piece describes the conceptual framework and the objectives that guided a research initiative in the Region of the Americas that was called "Gender, Equity, and Access to Health Services" and that was sponsored in 2001 by the Pan American Health Organization. The piece does not summarize the results of the six projects that were carried under the initiative, whose analyses have not all been completed. Instead, the piece discusses some of the foundations of the initiative and provides a general introduction to the country studies that were done. The six studies were done in Barbados/Jamaica, Brazil, Chile, Colombia, Ecuador, and Peru. The primary objective of the initiative was to stimulate the use of existing quantitative information in the countries, with the goal of starting a process of systematically documenting two things: 1) the unfair, unnecessary, and avoidable inequalities between men and women in their access to health care and 2) the linkages between those inequalities and other socioeconomic factors. The concept of gender equity that guided this examination of health care was not the usual one calling for the equal distribution of resources. Rather, it was the notion that resources should be allocated differentially, according to the particular needs of men and of women, and that persons should pay for health services according to their economic ability rather than their risk level. The starting point for the initiative was the premise that gender inequities in utilizing and paying for health care result from gender differences in the macroeconomic and microeconomic distribution of resources. The piece concludes that achieving equity in health care access will require a better understanding of the gender needs and gender barriers that are linked to social structures and health systems.

Barbados↗