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PubMed2004

Universal health care for Colombians 10 years after Law 100: challenges and opportunities.

Colombia's 1991 Constitution reformed the country's public health care system. Per constitutional mandate: (subsequently developed by Law 60/1993 and Law 100/1993), (1) health is a right of all citizens, (2) the Social Security System must coordinate, provide and control an effective, universal and collective public health service, (3) health services management and delivery are decentralized to strengthen the role of departments and municipalities, (4) the private sector is incorporated within the insurance and health services delivery functions, and (5) basic health services are free and compulsory. After summarizing some of the most relevant Colombia's health system features, this article addresses four central aspects of the country's health care reform, namely: (1) the Unit of Payment by Capitation (UPC) as a provider payment mechanism, (2) asymmetries of information among the different agents of the General System of Social Security in Health (SGSSS), (3) the delegation by the Fund of Solidarity and Assurance (FOSyGA) of collection and control functions to Health Promotion Entities (EPS), and (4) the attempt to achieve universal health insurance as defined by Law 100. The article concludes with a description of various measures and political decisions necessary to ameliorate the financial crisis of the SGSSS and overcome difficulties in reform implementation.

Colombia↗
PubMed1994

Job loss due to health insurance mandates.

The proposed Health Security Act provides universal health insurance by extending the current employer-based health insurance financing system. It requires employers to pay approximately 80% of the health insurance premium for each of their workers. Experience with other legislation requiring employers to provide benefits to their employees indicates that most of the cost of a mandated benefit is shifted to employees in the form of lower wages. However, for workers without health insurance and with earnings close to the minimum wage, minimum-wage legislation prohibits employers from lowering wages in response to a health insurance mandate. These employers can be expected to respond by cutting employment. Recent evidence from employer reactions to increases in the minimum wage suggests that approximately 100,000 jobs would be lost due to the Health Security Act's employer mandate.

Employment↗
PubMed1998

Psychiatric disorder onset and first treatment contact in the United States and Ontario.

OBJECTIVE: The authors describe the timing of the first treatment contact following new-onset DSM-III-R mood, anxiety, and addictive disorders in community samples from the United States and Ontario, Canada, before and after passage of the Ontario Health Insurance Plan. METHOD: The authors drew data from the National Comorbidity Survey (NCS) (N=8,098) and the mental health supplement to the Ontario Health Survey (OHS) (N= 9,953). They assessed psychiatric disorders with a modified version of the Composite International Diagnostic Interview; they also assessed retrospectively age at disorder onset and first treatment contact. They used the Kaplan-Meier method to generate time-to-treatment curves and survival analysis to compare time-to-treatment intervals across the two surveys. RESULTS: The overall time-to-treatment curves revealed substantial differences between disorders that were consistent across the two surveys. In both surveys, panic disorder had the highest probability of first-year treatment (NCS, 65.6%; OHS supplement, 52.6%), while phobia (NCS, 12.0%; OHS supplement: 6.5%) and addictive disorders (NCS, 6.4%; OHS supplement, 4.2%) had the lowest in both surveys. Retrospective subgroup analysis suggests that before the passage of the Ontario public insurance plan, the likelihood of receiving treatment in the year of disorder onset was greater in Ontario than in the United States but that this relationship reversed following passage of the Ontario plan. During this period, the authors observed no significant between-country differences in the probability of prompt treatment of adults with 12 or fewer years of education. CONCLUSIONS: These results challenge the assumption that the universal health insurance plan in Ontario promotes greater access to mental health services than is available in the United States for vulnerable groups. Marked differences between disorders in the speed to first treatment suggest that in both countries, clinical factors play an important role in the timing of the initial decision to seek treatment.

Adult↗
PubMed1997

Rural enrollment in MinnesotaCare.

Many rural Americans remain underserved and uninsured. Attempts to initiate national health care reform and universal health insurance coverage have stalled. The impetus to continue reform and universal coverage efforts has shifted back to the state level. Minnesota's health reform efforts resulted in the 1992 MinnesotaCare legislation, which included a subsidized insurance program. As of October 21, 1995, a total of 91,140 people were enrolled in MinnesotaCare. Enrollees are found in every county in the state and represent approximately 2.1% of Minnesota's total population and 2.4% of the state's population under age 65. Estimates of Minnesotans who are uninsured and therefore potentially eligible for this subsidized insurance plan range from 6% to 13%. MinnesotaCare enrollment estimates vary from a high of 10.8% of Red Lake County's population who are under age 65 and report incomes over 100% of the poverty level to a low of 1.5% for similar residents of Nicollet County. Counties with the lowest percentage of MinnesotaCare enrollees are clustered in southern Minnesota, especially the southeastern counties. Those with the highest percentage of enrollees appear to cluster in central Minnesota. MinnesotaCare enrollment is negatively associated with the size of the county's minority population and population density.

Adolescent↗
PubMed1997

Single payers and multiple lists: must everyone get the same coverage in a universal health plan?

In spite of recent political setbacks for the movement toward universal health insurance, considerable support remains for the idea. Among those supporting such plans, most assume that a universal insurance system, especially if it is a single-payer system, would offer a single list of basic covered services. This paper challenges that assumption and argues for the availability of multiple lists of services in a universal insurance system. The claim is made that multiple lists will be both more efficient and more fair. Any single list will fund some services that are quite attractive to some people, but only marginally attractive to others. Thus any single-list plan will fund some services that produce only marginal benefit for the resources used. Moreover, since some people will hold values quite compatible with the single list and others will hold values leading to preferences for unfunded services, some people will get much more benefit from any single list than other people will. Fairness and efficiency require providing an entitlement to universal access to health insurance that could be purchased by typical consumers for a fixed price of perhaps $3500. By permitting everyone to pick their preferred list of services available at that price, each person will efficiently use his or her entitlement while getting more equal opportunity for benefits.

Abortion, Induced↗
PubMed2002

Managed care--present day challenges and a working model for future consideration.

With the emergence of managed care as a dominant form of coverage for the American workforce and the concomitant growth in the number of uninsured and underinsured citizens, attention is increasingly focused on the development of cost-effective and efficient reimbursement strategies for the future. This manuscript provides both a summation of the different forms of coverage now available and a look at a possible future scenario through the only universal health insurance program now in place in the United States--Hawaii's health care system.

Consumer Behavior↗
PubMedDate not supplied

Making health equality a reality: the Bronx takes action.

In response to growing evidence of racial and ethnic disparities in health, Bronx Health REACH, a coalition of health care providers and community and faith-based organizations, is engaged in an effort to identify and eliminate the root causes of health disparities in their Bronx neighborhood. The group has gained a community perspective on health disparities that it has developed into a seven-point advocacy agenda: universal health insurance, an end to segregation in health facilities based on insurance status, accountability for state uncompensated care funds, culturally competent care for all, greater health workforce diversity, an expansion of public health education, and environmental justice.

Cultural Characteristics↗
PubMed2003

American Academy of Pediatrics Community Access to Child Health (CATCH) Program: a model for supporting community pediatricians.

Advocacy on behalf of children who are medically underserved and the pediatricians who care for them has been a long-standing core commitment of the Royal College of Paediatrics and Child Health and the American Academy of Pediatrics. Although different in etiology, barriers to adequate health care exist in both nations. In the United States, almost 18 million children have either no health insurance or inadequate coverage, whereas in the United Kingdom, parents can, in most cases, readily enroll their youngsters in a universal health insurance program that is not dependent on employers or employment.(1) However, despite universal access to health care in the United Kingdom, as in the United States, there are infants and children who do not regularly use or otherwise connect to available health care delivery systems. Many of these families are not participants in other social systems (eg, church, school, voting, employment, property ownership/rental) and therefore are not known to governments, agencies, authorities, or health care professionals. Both nations have citizens living in extreme poverty with its associated environmental and health hazards and tendencies to health risk behaviors. Both the Royal College of Paediatrics and Child Health and the American Academy of Pediatrics have strategies and programs to address these issues and to support pediatricians who work in their communities to improve the lives of children. The following describes the American Academy of Pediatrics Community Access to Child Health infrastructure that supports practicing community pediatricians in these efforts and opportunities to develop collaborative international endeavors to advance the practice of community pediatrics.

Child↗
PubMed1998

Ethnic-specific predictors of prenatal care utilisation in Hawaii.

The state of Hawaii has had near-universal health insurance coverage for the last 20 years. Its highly diverse population offers the opportunity for a unique, natural experiment in the United States on the examination of social differences in health care utilisation when financial barriers are removed. Therefore, the objective of this study is to examine predictors of prenatal care utilisation patterns in the four major ethnic groups in Hawaii. The data used in this study are the 1979-92 Hawaii livebirth vital record files. A total of 165,301 singleton livebirths to Hawaii-resident mothers of Caucasian, native Hawaiian, Japanese or Filipino ancestry were selected. Despite near-universal health care coverage in Hawaii, a surprising number of women did not adequately utilise prenatal care, with large differences between groups. Multivariate analyses indicated that similar maternal socio-demographic factors were associated with prenatal care use in each ethnic group. Social variation continues to exist among all ethnic groups even in the presence of universal access to care. These data emphasise the need to address the distinct cultural needs of populations for providing health services, and further challenge the assumption that removal of financial barriers will ensure a high level of prenatal care use.

Adolescent↗
PubMed2006

Massachusetts health care reform: a look at the issues.

Massachusetts recently enacted a major health reform that could move the state to close to universal health insurance coverage. We describe some of the politics behind the legislation and the law's key details. We discuss four major issues that the plan would face: (1) a definition of affordability-how much should be borne by individuals and how much by government; (2) issues the state will face in implementing the Insurance Connector; (3) whether employers will respond by dropping coverage; and (4) whether the financing would be adequate, both immediately and over time. Massachusetts will face challenges, but it offers a model that could be followed elsewhere.

Health Benefit Plans, Employee↗
PubMed2003

Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada: a population-based, multi-level modelling approach.

QUESTION ADDRESSED: This population-based study examines the factors affecting referrals by primary care physicians (PCPs) to specialists. MATERIALS AND METHODS: Multilevel Poisson models were used to test the impact of patient, physician and community-level variables on the referral rate (the number of office-based specialist referrals per patient by the patient's customary PCP in fiscal year 1997/98). Patients from each of 6972 PCPs with sufficient data in Ontario were examined. RESULTS: The average patient had 0.56 referrals per year (range 0-61). Referrals were higher at ages 1 and 77 to 78, and among women of childbearing age. Chronic disease variables were strongly correlated with referral rates. Patients in poor neighborhoods had more referrals, because they had more chronic diseases. After controlling for disease, individuals in the top 9% wealthiest neighborhoods had 4% more referrals. Female physicians made 8% more referrals than men. Older physicians referred more because they saw older patients; after controlling for patient age, physician age had no effect. Referrals were 14% higher in cities with medical schools compared with other cities and 12% lower in small towns. However, local specialist supply was unrelated to referral rates. CONCLUSION: This study improves our understanding of the impact of physician gender and age on referrals. It suggests that community type, not specialist supply, predicts variations in referrals. Lastly, it identifies preferential access to specialists among high-income earners, even within Canada's universal health insurance system. However, this effect is modest, suggesting that the system does provide reasonably equitable access to referrals.

Adolescent↗
PubMed1997

Taiwan's 1995 health care reform.

Under considerable domestic political pressure, the Taiwan government inaugurated a compulsory universal health insurance scheme on 1 March 1995. This new scheme is financed mainly by payroll tax and provides comprehensive health care benefits with a moderate cost sharing. In order to gain efficiency in delivering health services, the scheme enters contracts with health care providers and has been developing a prospective payment system. Meanwhile, the scheme uses a uniform fee schedule and makes all payments through a public single-payer system to control health care costs. By the end of the inaugural year, the scheme covered 92% of the population and the utilization pattern of the newly insured became close to that of the previously insured. However, there is the beginning of a financial crisis because the payments of the scheme are rapidly increasing and expect to exceed the premiums in the coming year. Besides, the scheme did not bring in the efficient use of health care resources and probably caused it to worsen. Taiwan's health care reform has an unfinished agenda.

Comprehensive Health Care↗
PubMed1998

Exposure to allopurinol and the risk of cataract extraction in elderly patients.

OBJECTIVE: To determine whether exposure to allopurinol is associated with an increased risk of cataract extraction in elderly patients. METHODS: We conducted a case-control study using data from the Quebec universal health insurance program for all elderly patients. The 3677 cases were patients with a cataract extraction between 1992 and 1994. The 21,868 controls were randomly selected among patients not diagnosed with cataract and matched to cases on the date of the extraction. We determined the odds ratio of cataract extraction according to the cumulative dose and duration of allopurinol use relative to nonusers, using conditional logistic regression analysis. The analysis was adjusted for the effects of age, sex, diabetes mellitus, hypertension, glaucoma, and ophthalmic and oral corticosteroid exposure. RESULTS: A cumulative dose of allopurinol of more than 400 g or a duration of use of longer than 3 years were associated with an increased risk of cataract extraction, with odds ratios of 1.82 (95% confidence interval [CI], 1.18-2.80) and 1.53 (95% CI, 1.12-2.08), respectively. No increase in risk was observed for lower cumulative doses or shorter exposure periods. CONCLUSION: Long-term administration of allopurinol increases the risk of cataract extraction in elderly patients.

Aged↗
PubMed2000

Fact and fiction: The medicare "crisis" seen from the United States.

There are at present two conflicting images of medicare available to the visitor from the United States. One is the conventional media portrait of crisis--from both U.S. and Canadian sources--an image of a program in deep trouble, overcome by problems of access, cost and quality. The other image is far more favourable: medicare as a structurally sound program of universal health insurance that largely satisfies those who use it, but, like all programs, requires managerial adjustment and attention to the fearfulness of medicare's future that has marked the last decade. This is the conclusion of the recent report of the Canadian Institute for Health Information (CIHI). Both portraits cannot be accurate, just as being green and white all over is logically impossible. What is the American interpreter to make of this dispute?

Attitude to Health↗
PubMed2006

Socioeconomic status and hospital utilization among younger adult pneumonia admissions at a Canadian hospital.

BACKGROUND: Although the general association between socioeconomic status (SES) and hospitalization has been well established, few studies have considered the relationship between SES and hospital length of stay (LOS), and/or hospital re-admission. The primary objective of this study therefore, was to examine the relationship of SES to LOS and early re-admission among adult patients hospitalized with community-acquired pneumonia in a setting with universal health insurance. METHODS: Four hundred and thirty-four (434) individuals were included in this retrospective, longitudinal cohort analysis of adult patients less than 65 years old admitted to a large teaching hospital in Vancouver, British Columbia. Hospital chart review data were linked to population-based health plan administrative data. Chart review was used to gather data on demographics, illness severity, co-morbidity, functional status and other measures of case mix. Two different types of administrative data were used to determine hospital LOS and the occurrence of all-cause re-admission to any hospital within 30 days of discharge. SES was measured by individual-level financial hardship (receipt of income assistance or provincial disability pension) and neighbourhood-level income quintiles. RESULTS: Those with individual-level financial hardship had an estimated 15% (95% CI -0.4%, +32%, p = 0.057) longer adjusted LOS and greater risk of early re-admission (adjusted OR 2.65, 95% CI 1.38, 5.09). Neighbourhood-level income quintiles, showed no association with LOS or early re-admission. CONCLUSION: Among hospitalized pneumonia patients less than 65 years, financial hardship derived from individual-level data, was associated with an over two-fold greater risk of early re-admission and a marginally significant longer hospital LOS. However, the same association was not apparent when an ecological measure of SES derived from neighbourhood income quintiles was examined. The ecological SES variable, while useful in many circumstances, may lack the sensitivity to detect the full range of SES effects in clinical studies.

Adolescent↗
PubMed1985

Payment for psychiatric services under Canada's insurance system.

The authors review the impact of Canada's universal health insurance system on the delivery of psychiatric services. They believe that, on balance, Canadian psychiatrists and their patients have benefited from the system. However, certain categories of patients still do not have access to private care, and public facilities in some provinces have long waiting lists for services because of manpower shortages. A substantial number of psychiatrists have opted out of the system because of dissatisfaction with the intrusion of third-party payment on practice. The Canadian system presently discourages copayment by patients, and thus has reinforced the public's belief in free medical care as a right. The authors discuss the benefits to some patients of direct payment for services and emphasize the need for direct payment to remain an option under national health insurance.

Canada↗
PubMed2000

Universal health care? The views of Negev Bedouin Arabs on health services.

BACKGROUND: This study examines health and health care attitudes, practices and utilization patterns among the Bedouin Arab minority in the south of Israel. Particular attention is given to the effects of the new National Insurance Law that provides universal coverage for the first time, and to the identification of critical issues for further research. METHODS: Focus groups, adapted to Bedouin culture, were the primary method of data collection. Twelve groups (158 participants) from throughout the Negev met for 3-7 sessions each, using specially trained local moderators and observers. Issues discussed and analyzed included experience and satisfaction with the current health system (both modern and traditional), health service availability/barriers, health care needs, influences of social change, and the National Insurance Law. RESULTS: Participants voice dissatisfaction with modern health services in the Bedouin sector and the state of health of Negev Bedouin. They place great emphasis on the connection between health and the rapid social and economic changes, which this traditionally nomadic group is undergoing. Traditional health care is felt to still exist, but its importance is waning. The National Insurance law is having a major impact on the Bedouin, particularly because it provides universal health insurance coverage where only partial coverage had been in effect. CONCLUSIONS: This study, one of the first of its kind in the Bedouin sector, showed that the focus group method, if properly modified to cultural norms, can be a valuable research tool in traditional communities and in health service research. The findings from this research can be used to direct efforts to improve health policy and health services for this group, as well as preparing the way for further qualitative or quantitative studies.

Arabs↗