Incremental approaches to covering uninsured children: design and policy issues

More than 10.5 million children were uninsured throughout 1995. The number of uninsured children remains high, even in the face of continued expansions of Medicaid designed to cover low-income children. As a result, interest persists in developing additional approaches for covering uninsured children. Efforts to attract more uninsured children will entail important trade-offs between the federal costs of the program (and its political viability) and the number of uninsured children who enroll.

The status of local health care safety nets

This paper examines variations in the composition, concentration, financing, and community context of local health care "safety nets" and the market pressures that they face. It also reviews financing mechanisms that support these systems and strategies being undertaken to retain publicly insured patients. As safety-net providers compete more aggressively, the availability of the public health, behavioral health, and social services they provide may be affected. Communities may have to consider more explicit investments in these "public goods" if competitive markets remove existing cross-subsidies.

The evolution of support for safety-net hospitals

The federal government, mostly through the Medicare and Medicaid programs, has created and maintained a set of structural mechanisms to support uncompensated care and clinical education: disproportionate-share hospital payments and direct and indirect graduate medical education payments. This paper provides a history of how these traditional supports have evolved. We note that the need to reduce federal and state spending threatens the level of these payments, while changes in the health care delivery system highlight a range of design and technical inadequacies in the current support mechanisms.

A cross-sectional study of private psychiatric practices under a single-payer health care system

OBJECTIVES

To examine current concerns that in the Canadian single-payer mental health care system, the "rich worried well" (that is, wealthy individuals who are worried yet mentally well) may overuse psychiatric services, while low-income, uninsured mentally ill individuals may remain undertreated. The current study focuses on the mental health care in the Canadian region of Ottawa-Carleton, where a single-payer system provides universal access to mental health services, to assess how psychiatric services are provided by psychiatrists in private practice.

METHOD

One hundred and seven private psychiatrists working in the region of Ottawa-Carleton completed a questionnaire which contained questions about the sociodemographic characteristics and background of the psychiatrists themselves and which asked the psychiatrists specific questions about the sociodemographic status, diagnosis, and treatment of each patient seen on November 10, 1994.

RESULTS

Approximately 93% of the patients seen met criteria for one or more Axis I disorders, of which mood and anxiety disorders were the most common. Wealthier patients were relatively underrepresented among the patients treated by the private psychiatrists. In addition, we found no significant differences in the distribution of Axis I, Axis II, and Axis III disorders between patients earning below $30,000 per year compared with patients earning above $60,000 per year.

CONCLUSIONS

Our results suggest that outpatient psychiatric care delivered by private psychiatrists in a Canadian single-payer system targets primarily individuals with major psychiatric disorders and does not seem to favour "the worried well." Larger epidemiological studies with independent assessments of psychiatric populations are necessary to confirm our findings.

In the same boat. For-profit, not-for-profit hospitals face peril of tax reform

The ongoing, escalating rift between for-profit and not-for-profit hospitals could be the crowbar that pries open the Pandora's box of tax reform, an issue so complicated and fraught with political peril it makes Medicare reform look easy. While everyone waits for congressional leaders to signal their intentions, people from both ownership sectors are laying the groundwork for future action.

Early diagnosis and treatment of malaria in a refugee population in Sri Lanka

To provide early diagnosis and prompt treatment for malaria, two interventions were compared in refugee camps in Kalpitiya, Sri Lanka. Community health volunteers (HV's) were trained in diagnosis and management of malaria on clinical grounds, while a field laboratory was established in another group of camps providing treatment after laboratory confirmation of a malarial infection. Patients with fever sought treatment from HV's on average after 2.74 days and from the field laboratory after 3.20 days. Although acceptance of both interventions was high, the effective catchment areas, especially of the HV's were small. Large numbers of health volunteers would be needed to cover all families, making it difficult to sustain supervision and necessary logistic support. For every malaria patient treated by HV's, three others would receive anti-malarial drugs unnecessarily. The maintenance of a field laboratory with a microscopist of the Anti-Malaria Campaign is not an economically viable option. Training of HV's in microscopy with a mechanism for cost recovery should be given serious consideration. HV's and diagnosis and treatment centers should be able to handle a wide spectrum of common diseases. A better option for Sri Lanka in the short term might be to improve existing general health facilities that are accessible to the refugee population.

The value and use of the Qualified Medicare Beneficiary Program: early evidence from Tennessee

The Qualified Medicare Beneficiary (QMB) Program eliminated the out-of-pocket costs of obtaining health care services under the Medicare program for some low-income beneficiaries who were previously ineligible for Medicaid. The program is underused, and little is known about its effects. The article describes the QMB Program and compares program beneficiaries with others whose out-of-pocket payments are covered by Medicaid. Using Medicare claims data covering QMBs in Tennessee, we found that the program financed a relatively high rate of use of Medicare services and saved low-income Medicare beneficiaries hundreds of dollars per month in out-of-pocket costs. Social workers can promote the program and increase the use of its covered services appropriately, thereby by maximizing its potential benefits to low-income people.

Living on the edge: dietary strategies of economically impoverished women in Cali, Colombia

Economically impoverished women in Cali, Colombia, have restricted access to food in a city where food is abundant. Ethnographic observations, interviews and 2 day food records were used to better understand the coping strategies used by a group of these women (n = 85) to maintain adequate levels of energy intake. Anthropometric indicators of nutritional status were normal for the group. Interview data revealed that the ability to purchase food was a concern for 58% of the women. When faced with a restricted ability to purchase food, the women indicated they made compromises in meal composition, reduced portion sizes, and/or reduced the number of meals. They also relied on relatives, friends, neighbors, store credit, or local government programs for access to food. Changes in meal composition were identified in 17.1% of all diet records (n = 509). Low energy intake (defined as energy intake < or = 1.27 x BMR) was identified in 17.1% of all diet records. Carbohydrate consumption was significantly greater on low-energy intake days. The adequate nutritional status of this group of women suggests that their coping strategies are usually adequate to maintain energy intake, but the presence of uncertainty, the frequency of compromises in diet composition, and the frequency of low-energy intake days suggest that these women are at risk for undernutrition.

Impacts of the proposed restructuring of Medicare and Medicaid on the elderly: a conceptual framework and analysis

The article examines the proposed transformations in U.S. Medicare and Medicaid as these are likely to affect the nation's elderly population. Drawing on political economy, moral economy, and notions of the deserving versus the undeserving poor, the authors develop a broad conceptual framework within which to better understand the current upheavals. Both Republican and Democratic proposals for restructuring Medicare and Medicaid are described and analyzed, and common themes within the various proposals highlighted. After exploring the differential impacts of the restructuring on subgroups within the elderly population, including low-income seniors, the disabled, women, and elders of color, the authors conclude with a discussion of the symbolic importance of the proposed transformations. The latter reflect both accelerated government movement away from its legitimation functions and toward increased capital accumulation, and continuing government attempts to reshape our perceptions of the state economy in ways that permit more radical cutbacks and austerity measures.

Provision of free and discounted dental services to selected populations: a survey of attitudes and practices of dentists attending the 1996 Dallas Midwinter Meeting

An attitudes and practices survey of dentists attending the Dallas Midwinter Meeting in January 1996 in Dallas was conducted as a collaborative effort between the Dallas County Dental Society and the Baylor College of Dentistry. The survey was developed to help determine participating dentists' attitudes and practices in the area of provision of dental services on a discounted or free basis to disadvantaged patient groups. A total of 225 dentists responded to the survey. Of these surveyed dentists, 213 (94.6%) were in private practice and 199 (88.4%) described themselves as general dentists. A considerable amount of charitable dental services, discounted and free, was reported to be provided by the group of respondent dentists. A total of 152 (67.6%) of the dentists surveyed reported providing discounted or free care to elderly patients with low income, 125 (55.6%) provided such care to low-income patients without age restriction, and 137 (60.9%) cared for patients of record with temporary financial hardship. In other patient categories, 79 (35.1%) of the dentists provided free/discounted services to handicapped persons and 47 (20.9%) provided care to homebound patients. These findings concerning charitable practices by dentists were similar to those found in a comparable survey conducted by the American Dental Association in 1994. Dentists were fairly evenly split as to their preference where to volunteer services. Of the total respondents, 84 (40.6%) preferred providing services in their own office and 91 (44.0%) preferred to do so at a community health clinic that hosted volunteers.

Prescribed medication and nutrition of social care patients in Crete, Greece

OBJECTIVE

The aim of this study was to make a systematic registration of a group of 354 social care indigent patients in relation to: their pharmaceutical needs: the conditions for which it was prescribed, its cost, and details of prescriptions. In addition patients' eating patterns relating to and knowledge of how to use their medication was assessed. They were compared to a control group of 153 Social Security patients.

SUBJECTS

The Social Care indigent patients were of low income, consisting of groups as unmarried mothers with their children and Greeks emigrants coming back home from other countries (Albania, Russia, Georgia, Ukraine, Romania etc.). The socio-demographic profiles of this group reveal an unemployment rate of 74% and an illiteracy rate of 18%. As regards marital status, 20% are bachelors and 12% divorcees.

RESULTS

The results of the study indicated no significant difference between the two groups in the mean cost of prescription (40 ECU for Social Care patients vs 32 ECU for Social Security patients), in the mean number of medication per prescription (2.6 vs 2.6 respectively), in the percentages of the Daily Defined Doses and the cost of the various categories of drugs. For both groups, the most common drugs were those of the Cardiovascular system (30% vs 26%), Gastrointestinal system (17% vs 27%) and Nervous system (16% vs 18%). The most common diagnosis was Hypertension (10% vs 8%) and the most common drugs were Ranitidine (3% vs 2%), Diclofenac (3% vs 3%), Salbutamol (3% vs 3%) and Paracetamol (2% vs 2%). Significant differences between Social Care patients to Social Security patients respectively were found regarding: knowing how to take their medication correctly (47% vs 77%), knowing for how long treatment needed to be taken (21% vs 43%), requesting information from the pharmacist (39% vs 68%) knowledge of dietary instructions regarding medication (17% vs 41%) and in smoking more than 20 cigarettes per day (15% vs 3%).

CONCLUSIONS

The results indicated that the Social Care patients, in comparison with the patients of the Social Security, need more education and more help in the area of the proper use of drugs and in the personal contact that this procedure involves.

Potential cost savings for Medi-Cal, AFDC, food stamps, and WIC programs associated with increasing breast-feeding among low-income Hmong women in California

OBJECTIVE

To determine the potential cost savings for four social service programs if breast-feeding rates increased among Hmong women in California.

DESIGN

Cost-savings analysis.

SUBJECTS/SETTING

Hmong women in California. In this population, breast-feeding is currently uncommon, and use of contraceptives is minimal.

MAIN OUTCOME MEASURES

Savings were based on estimates of the resulting decrease in infant morbidity, maternal fertility, and formula purchases (Special Supplemental Nutrition Program for Women, Infants, and Children) if women breast-fed each child for at least 6 months. Costs were projected over a 7.5-year period and future values were discounted with annual interest rates of 2% or 4%.

RESULTS

Substantial savings estimates were associated with breast-feeding for all four programs. The total projected savings over the 7.5-year period ranges from $3,442 to $4,944 (4% discount) to $4,475 to $6,0960 (0% discount) per family enrolled in all four programs. This translates into an estimated yearly savings of between $459 and $659 (4% discount) and $597 and $808 (0% discount) per family.

APPLICATIONS

Although health care providers generally accept that breast-feeding is the preferred method for feeding infants, many still view the choice as a neutral one; that is, they consider low breast-feeding rates in the United States a cultural choice with no cost to society. This analysis provides evidence that breast-feeding is economically advantageous for individuals and society.

The response of injection drug users to free treatment on demand: implications for HIV control

Injection drug use is a major risk factor for human immunodeficiency virus (HIV) infection and drug treatment is widely recognized as a core component of the public health effort to limit the spread of HIV. The assumption is frequently made that lack of immediate access to treatment is a significant barrier to the success of this effort. However, little empirical data exist to support this belief. We conducted a trial of no-cost outpatient drug-free treatment made available on demand to a cohort of out-of-treatment injection drug users (IDUs) in Portland, Oregon, through a coupon program. Of 824 IDUs, 272 (33%) expressed an interest in treatment, 225 (27%) accepted a coupon, 66 (8%) redeemed a coupon, and 9 (1%) remained in treatment for 6 months. These numbers indicate that simply enhancing access is not adequate. Additional strategies to increase motivation to enter and remain in treatment are needed if drug treatment is to play an important role in reducing the spread of HIV among injection drug users, their sexual partners, and their infants.

Income class and pharmaceutical expenditure in Canada: 1964-1990

In the 1970s, nearly all Canadian provinces introduced drug programs to subsidize purchases by low-income families. This study was undertaken to determine whether these programs were successful in reducing out-of-pocket pharmaceutical expenditures for low-income families and individuals, and to compare expenditures in this group with those of high-income families. Expenditures were calculated for a low- and a high-income group from Statistics Canada surveys conducted between 1964 and 1990. In the low-income group there was a 40% decline in drug expenditure measured as a percentage of total family expenditure and this was coincident with the introduction of provincial drug programs. However, the high-income group had an even larger decrease in drug expenditure. Per capita spending as a percentage of total family expenditure in the low-income group, was seven times that of the high-income group and there was no change in this ratio after the introduction of the drug plans.

Market commodities and poor relief: the world bank proposal for health

Investing in Health is the World Bank's blueprint for a new health policy within the context of structural adjustment. While this document includes a broad range of arguments, its implicit premises are neoliberal as can be deduced from its "agenda for action." Health is defined as a private responsibility and health care as a private good. This leads to a health policy based on two complementary principles: the reduction of state intervention and public responsibility, and the promotion of diversity and competition (i.e., privatization). Thus, public institutions should provide only a limited number of public goods and narrowly defined, cost-efficient forms of relief for the poor. All other health-related activities are considered private duties, to be resolved by the market, NGOs, or families. The World Bank policy provides a pragmatic contribution to efforts to achieve fiscal balance. However, it also pushes to recommodify health care and to turn health into a terrain for capital accumulation through the selective privatization of health-related financial and "discretionary" services. The proposal implies large-scale experimentation and dismantling of public institutions which are the only alternative now accessible to the majority. It rejects health as a human need and a social right, and violates basic values by claiming that life and death decisions can be justly made by the market or through a cost-effectiveness formula.

Re-engineering the public hospital system: saving the safety net

Cities across America are grappling with the problem of how to provide care for the indigent and those on Medicaid. All levels of government are reducing their public funding for health care of indigent persons, and the rapid growth of managed care is making traditional cost-shifting more difficult as it transforms the practice of medicine itself. These issues are most acute in cities like Los Angeles and New York, which traditionally have relied on public hospital systems to serve as a safety net. This article focuses on the changes being wrought at the largest health-care system in the country for indigents, the New York City Health and Hospitals Corporation (HHC), on the progress it made during the first 18 months of a major re-engineering process, and on potential options for its future reform.

Paying physicians for charity care

The Internal Revenue Service's (IRS's) Announcement 95-25 gives important new legal support to the practice of compensating physicians for providing charity care. The announcement describes a situation in which tax-exempt hospitals may compensate non-employee physicians who are members of their staffs for providing charity care--a practice that in the past has had only indirect legal support. Before creating arrangements to compensate physicians for charity care, however, healthcare executives first must establish guidelines that ensure the arrangements comply with IRS rules and Federal antikickback laws. Careful planning on the part of healthcare executives can ensure that an important community service is provided without jeopardizing the hospital's tax-exempt status or exposing it to monetary penalties.