The mission of safety net organizations following national insurance reform

User fee removal for the poor: a qualitative study to explore policies for social health assistance in Iran

Introduction

Removal of user fee for vulnerable people reduces the financial barriers associated with healthcare payments, which, in turn, improves health outcomes and promotes health equity. This study sought to provide policy strategies to reduce user fee at the point of service delivery for the poor in Iran.

Methods

This is a qualitative study carried out in 2018. The purposive sampling method was applied, and 33 experts with relevant and valuable experiences and maximum variation to obtain representativeness and rich data were interviewed. Trustworthiness criteria were used to assure the quality of the results. The data were analyzed based on thematic analysis using the MAXQDA10 software.

Results

The most important issue regarding financial protection against user fee for the poor in Iran is policy integration and cohesion. Differences in access to financial support for user fee coverage among different groups of the poor have led to inequalities in access and financial protection among the poor. The suggested protection policies against the user fee at the point of service delivery in Iran can be categorized into three main categories: 1) basic health social insurance instruments, 2) free health services to the poor outside of the health insurance system, and 3) complementary insurance mechanisms.

Conclusion

Implementing a cohesive social assistance policy for all disadvantaged groups is needed to address inequalities in financial protection against user fee payment among the poor in Iran. Reducing user fee through mechanisms such as deductible cap, stop-loss, variable user fee and sliding fee scale can improve financial protection and enhance healthcare utilization among the poor. A user fee exemption is not enough to remove barriers to access to service for the poor, as other costs such as transportation expenditures and informal payments also put financial pressure on them. Therefore, financial support for the poor should be designed in a comprehensive protection package to reduce out-of-pocket payments for healthcare services, and indirect costs associated with healthcare utilization.

Changes in primary care access at community health centers between 2012/2013 and 2016

OBJECTIVE

To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act.

DATA SOURCE

Ten state primary care audit conducted in 2012/2013 and 2016.

STUDY DESIGN

CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type.

PRINCIPAL FINDINGS

In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance.

CONCLUSION

Appointment availability at CHCs improved after ACA implementation, without increased wait times.

Adapting to a Shifting Health Care Landscape: Illinois Breast and Cervical Cancer Program Lead Agencies' Perspectives

Understanding how safety net programs adapt to systemic health care changes is pivotal for creating feasible recommendations for policy implementation. This study characterizes perspectives of Lead Agency (LA) coordinators of the Illinois Breast and Cervical Cancer Program (IBCCP) in response to sociopolitical changes at state and national levels. Our cross-sectional study included 29 semistructured telephone interviews between December 2015 and January 2016. Respondents indicated some changes in the priority population served, changes in referrals and clinical services, and, a continued commitment to IBCCP. Our findings suggest that IBCCP and other safety net programs will need to be flexible to meet the ongoing needs of historically vulnerable populations in a complex, shifting environment. Implications for public health practice and policy include the need to ensure that program personnel are aware of evidence-based strategies to reach different priority populations and are kept abreast of organizational and system changes that may affect referral patterns as well as the need to educate health care providers working with safety net programs about changes in the delivery and coordination of services.

International examples of undocumented immigration and the affordable care act

As it stands there is no viable health care option for undocumented immigrants of low socioeconomic status. Even more worrisome is that Affordable Care Act simply does not address this issue with any direct plan. The US is in a very influential time period in terms of undocumented immigration and its relationship with health care. The purpose of this paper is to examine international examples of undocumented immigrant health care and their implications for the United States' undocumented immigrant health care. This study found that physicians in the US must work to prevent the initiation of policies which exclude undocumented immigrants from accessing health care. Exclusionary policies implemented in European nations have had disastrous effects on physicians and patients. This paper examines the implications which similar policies would have if implemented in the US.

Health disparities and underserved populations: a potential solution, medical school partnerships with free clinics to improve curriculum

Health-care educators share the social responsibility to teach medical students about social determinants of health and health-care disparities and subsequently to encourage medical students to pursue residencies in primary care and medical practice in underserved communities. Free clinics provide care to underserved communities, yet collaborative partnerships with such organizations remain largely untapped by medical schools. Free clinics and medical schools in 10 US states demonstrate that such partnerships are geographically feasible and have the potential to mutually benefit both organizational types. As supported by prior research, students exposed to underserved populations may be more likely to pursue primary care fields and practice in underserved communities, improving health-care infrastructure.

Implementation of the Affordable Care Act and rural health clinic capacity in Iowa

OBJECTIVE

To evaluate the capacity of rural health clinics (RHCs) in Iowa as the Affordable Care Act (ACA) is implemented.

METHODS

We developed and fielded an online survey among the 142 RHCs in Iowa.

RESULTS

The survey response rate was 19% and this exceeds the response rate of previously published RHC studies. Responding RHCs report struggling to provide dental care and mental health services, and indicate a high degree of recruiting difficulty for physicians (80%), physician assistants, and nurse practitioners (both 50%), with referrals to specialists being common. Nearly 60% of RHC respondents anticipate an increase in the size of their patient population because of the ACA, with 14.8% expecting a substantial increase. Respondents indicated a lack of preparedness for participating in a value-based health care delivery system. While nearly all RHC respondents (90.4%) report knowing what steps they need to take to respond to the challenges health reform may present, only 19% agree that they have the human, financial, and material resources necessary to respond to those challenges.

CONCLUSION

RHCs have limited capacity to respond to the opportunities and challenges of the ACA, and need additional resources and incentives to thrive in a reformed health care delivery system.

Rural-urban differences in consumer governance at community health centers

CONTEXT

Community health centers (CHCs) are primary care clinics that serve mostly low-income patients in rural and urban areas. They are required to be governed by a consumer majority. What little is known about the structure and function of these boards in practice suggests that CHC boards in rural areas may look and act differently from CHC boards in urban areas.

PURPOSE

To identify differences in the structure and function of consumer governance at CHCs in rural and urban areas.

METHODS

Semistructured telephone interviews were conducted with 30 CHC board members from 14 different states. Questions focused on board members' perceptions of board composition and the role of consumers on the board.

FINDINGS

CHCs in rural areas are more likely to have representative boards, are better able to convey confidence in the organization, and are better able to assess community needs than CHCs in urban areas. However, CHCs in rural areas often have problems achieving objective decision-making, and they may have fewer means for objectively evaluating quality of care due to the lack of patient board member anonymity.

CONCLUSIONS

Consumer governance is implemented differently in rural and urban communities, and the advantages and disadvantages in each setting are unique.

Who governs federally qualified health centers?

To make them more responsive to their community's needs, federally qualified health centers (FQHCs) are required to have a governing board comprising at least 51 percent consumers. However, the extent to which consumer board members actually resemble the typical FQHC patient has not been assessed, which according to the political science literature on representation may influence the board's ability to represent the community. This mixed-methods study uses four years of data from the Health Resources and Services Administration, combined with Uniform Data System, Bureau of Labor Statistics, and Area Resource File data, to describe and identify factors associated with the composition of FQHC governing boards. Board members are classified into one of three groups: nonconsumers, nonrepresentative consumers (who do not resemble the typical FQHC patient), and representative consumers (who resemble the typical FQHC patient). The analysis finds that a minority of board members are representative consumers, and telephone interviews with a stratified random sample of thirty FQHC board members confirmed the existence of significant socioeconomic gaps between consumer board members and FQHC patients. This may make FQHCs less responsive to the needs of the predominantly low-income communities they serve.

Medicaid Disproportionate Share Hospital payment: how does it impact hospitals' provision of uncompensated care?

This study examines the association between hospital uncompensated care and reductions in Medicaid Disproportionate Share Hospital (DSH) payments resulting from the 1997 Balanced Budget Act. We used data on California hospitals from 1996 to 2003 and employed two-stage least squares with a first-differencing model to control for potential feedback effects. Our findings suggest that nonprofit hospitals did reduce provision of uncompensated care in response to reductions in Medicaid DSH, but the response was inelastic in value. Policymakers need to continue to monitor uncompensated care as sources of support for indigent care change with the Patient Protection and Affordable Care Act (ACA).