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Aderinto N, Olatunji G, Kokori E, Abdulrahmon MA, Akinmeji A, Fatoye JO. Expanding surgical access in Africa through improved health insurance schemes: A review. Medicine (Baltimore) 2024; 103:e37488. [PMID: 38489736 PMCID: PMC10939550 DOI: 10.1097/md.0000000000037488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 03/17/2024] Open
Abstract
Surgical access remains a pressing public health concern in African nations, with a substantial portion of the population facing challenges in obtaining safe, timely, and affordable surgical care. This paper delves into the impact of health insurance schemes on surgical accessibility in Africa, exploring the barriers, challenges, and future directions. It highlights how high out-of-pocket costs, reliance on traditional healing practices, and inadequate surgical infrastructure hinder surgical utilization. Financing mechanisms often need to be more effective, and health insurance programs face resistance within the informal sector. Additionally, coverage of the poor remains a fundamental challenge, with geographical and accessibility barriers compounding the issue. Government policies, often marked by inconsistency and insufficient allocation of resources, create further obstacles. However, strategic purchasing and fund integration offer avenues for improving the efficiency of health insurance programs. The paper concludes by offering policy recommendations, emphasizing the importance of inclusive policies, streamlined financing mechanisms, coverage expansion, and enhanced strategic purchasing to bridge the surgical access gap in Africa. Decoupling entitlement from the payment of contributions, broadening the scope of coverage for outpatient medicines and related expenses, and enhancing safeguards against overall costs and charges, especially for individuals with lower incomes. Ultimately, by addressing these challenges and harnessing the potential of health insurance schemes, the continent can move closer to achieving universal surgical care and improving the well-being of its people.
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Affiliation(s)
- Nicholas Aderinto
- Department of Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
| | - Gbolahan Olatunji
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | - Emmanuel Kokori
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | | | - Ayodeji Akinmeji
- Department of Medicine, Olabisi Onabanjo University, Ogun, Nigeria
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Cliff BQ, Siegel N, Panzer J, Deis E, Patel A, Edmiston C, Stiehl E. Effects of Advanced Team-Based Care on Care Processes and Health Measures in a Federally Qualified Health Center. J Ambul Care Manage 2024; 47:33-42. [PMID: 37994512 DOI: 10.1097/jac.0000000000000484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
In a federally qualified health center, we assess a novel primary care delivery model, advanced team-based care (aTBC), that embeds care team members in patient visits. Using a difference-in-differences research design, we measure visit intensity, compliance with preventive care recommendations, and health outcomes among patients in the aTBC model compared with patients in a traditional team-based delivery model. We find increases in receipt of some recommended preventive care and in visit intensity, but no change in health outcomes. The aTBC model may improve some dimensions of care quality for low-income, vulnerable populations.
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Affiliation(s)
- Betsy Q Cliff
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois (Dr Cliff); Division of Health Policy and Administration, University of Illinois Chicago School of Public Health, Chicago (Mss Siegel and Edmiston and Dr Stiehl); and Tapestry 360 Health, Chicago, Illinois (Drs Panzer and Patel and Ms Deis)
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Koblinski JE, Greene A, Quillen JK, Zhang N, Rosman IS, Ochoa SA, Costello CM. Racial/Ethnic Disparities in Dermatology Research Fellowship Funding. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01757-5. [PMID: 37608135 DOI: 10.1007/s40615-023-01757-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
Dermatology is a competitive field for applicants pursuing a residency, and many applicants turn to dedicated research years to try and increase their competitiveness. Our study aimed to determine the financial costs of a research year and uncover how the costs of a research year vary for different demographic groups. We administered an anonymous survey through various dermatology listservs and social media platforms to prior, current, and future dermatology applicants who had completed a research fellowship during or after medical school. We found the median total fellowship cost ($26,443.20) was higher than the median fellowship income ($23,625.00). Furthermore, we found minority respondents had significantly lower total income, lower fellowship income, and higher net fellowship cost (p<0.05). Ninety participants completed surveys, and over half reported their research year as financially stressful. The majority did state that if given the opportunity, they would choose to do their research year again. Given the overall high costs of research years and the disparity in funding of these years, steps should be taken to address the disparities in fellowship funding or de-emphasize the importance of research fellowships in the dermatology residency selection process.
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Affiliation(s)
| | - Adina Greene
- College of Medicine, University of Arizona - Phoenix, Phoenix, AZ, USA
- Department of Dermatology, Mayo Clinic, 13400 E Shea Blvd, 85259, Scottsdale, AZ, USA
| | - Jaxon K Quillen
- Department of Qualitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Nan Zhang
- Department of Qualitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Ilana S Rosman
- Division of Dermatology, Washington University, St. Louis, MO, USA
| | - Shari A Ochoa
- Department of Dermatology, Mayo Clinic, 13400 E Shea Blvd, 85259, Scottsdale, AZ, USA
| | - Collin M Costello
- Department of Dermatology, Mayo Clinic, 13400 E Shea Blvd, 85259, Scottsdale, AZ, USA.
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Camargo JT, Ramirez M, Gajewski BJ, Sullivan DK, Carlson SE, Gibbs HD. Nutrition Literacy Among Latina/x People During Pregnancy Is Associated With Socioeconomic Position. J Acad Nutr Diet 2022; 122:2097-2105. [PMID: 35589070 DOI: 10.1016/j.jand.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND During pregnancy, Latina/x people experience nutrition and nutrition-related health inequities. Nutrition literacy is a potential factor impacted by these inequities. However, the nutrition literacy level of Latina/x people during pregnancy is not well investigated. OBJECTIVES The study aimed to assess the nutrition literacy level of Latina/x people during pregnancy and explore the association of nutrition literacy with socioeconomic position. DESIGN This was a cross-sectional study of data collected from 2016 to 2018 within the double-blinded, randomized clinical trial Assessment of Docosahexaenoic Acid on Reducing Early Preterm Birth. PARTICIPANTS/SETTING A total of 112 Latina/x people during pregnancy from the Kansas City metro area were included in this study. MAIN OUTCOME MEASURES Nutrition literacy level assessed between 12 and 20 gestational weeks using the Nutrition Literacy Assessment Instrument, both in English and Spanish. STATISTICAL ANALYSES PERFORMED Descriptive measures were used to describe the nutrition literacy level during pregnancy. Multiple logistic regression models were used to examine the association between low nutrition literacy and socioeconomic position, adjusting for age and race. RESULTS In this study, most participants demonstrated low nutrition literacy during pregnancy. Those with low nutrition literacy were 2 times more likely to have low annual household income (odds ratio [OR] = 2.74, 95% confidence interval [CI]: 0.99-7.59), 3 times more likely to prefer Spanish as their primary language of communication (OR = 3.03, 95% CI: 0.95-9.67), and 7 times more likely to be uninsured (OR = 7.47; 95% CI: 1.57-35.64). CONCLUSIONS Nutrition literacy scores during pregnancy were associated with variables of socioeconomic position. Future research should focus on nutrition literacy associations with health outcomes during pregnancy and interventions to improve the nutrition literacy level of primarily Spanish-speaking people who have low household incomes and are uninsured.
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Affiliation(s)
- Juliana T Camargo
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas; Department of Urology, University of Kansas Medical Center, Kansas City, Kansas
| | - Mariana Ramirez
- JUNTOS Center for Advancing Latino Health, Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
| | - Byron J Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Debra K Sullivan
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas
| | - Susan E Carlson
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas
| | - Heather D Gibbs
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas.
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Gopalan M, Lombardi CM, Bullinger LR. Effects of parental public health insurance eligibility on parent and child health outcomes. ECONOMICS AND HUMAN BIOLOGY 2022; 44:101098. [PMID: 34929550 PMCID: PMC9301861 DOI: 10.1016/j.ehb.2021.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/29/2021] [Accepted: 12/08/2021] [Indexed: 06/14/2023]
Abstract
Many states expanded their Medicaid programs to low-income adults under the Affordable Care Act (ACA). These expansions increased Medicaid coverage among low-income parents and their children. Whether these improvements in coverage and healthcare use lead to better health outcomes for parents and their children remains unanswered. We used longitudinal data on a large, nationally representative cohort of elementary-aged children from low-income households from 2010 to 2016. Using a difference-in-differences approach in state Medicaid policy decisions, we estimated the effect of the ACA Medicaid expansions on parent and child health. We found that parents' self-reported health status improved significantly post-expansion in states that expanded Medicaid through the ACA by 4 percentage points (p < 0.05), a 4.7% improvement. We found no significant changes in children's use of routine doctor visits or parents' assessment of their children's health status. We observed modest decreases in children's body mass index (BMI) of about 2% (p < 0.05), especially for girls.
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Yabroff KR, Zhao J, Halpern MT, Fedewa SA, Han X, Nogueira LM, Zheng Z, Jemal A. Health Insurance Disruptions and Care Access and Affordability in the U.S. Am J Prev Med 2021; 61:3-12. [PMID: 34148626 DOI: 10.1016/j.amepre.2021.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Health insurance is associated with better care in the U.S., but little is known about the associations of coverage disruptions (i.e., periods without insurance) with care access, receipt, and affordability. METHODS Adults aged 18-64 years with current private (n=124,746), public (n=30,932), or no (n=31,802) insurance coverage were identified from the 2011-2018 National Health Interview Survey. Data were analyzed in 2020. Separate multivariable logistic regressions evaluated the associations of having coverage disruptions or being uninsured with care access, receipt, and affordability. RESULTS Overall, 5.0% of currently insured adults with private and 10.7% with public insurance reported a coverage disruption in the previous year, representing nearly 9.1 million adults in 2018. Among currently uninsured, 24.9% reported coverage loss within the previous year, representing nearly 8.1 million adults in 2018. Among adults with current private or current public coverage, disruptions were associated with lower receipt of all preventive services (AOR=0.42, 95% CI=0.37, 0.46 and AOR=0.48, 95% CI=0.40, 0.58, respectively), with forgoing any needed care because of cost (AOR=4.79, 95% CI=4.44, 5.17 and AOR=4.28, 95% CI=3.86, 4.75), and with medication nonadherence because of cost (AOR=3.55, 95% CI=3.13, 4.03 and AOR=4.09, 95% CI=3.43, 4.88) compared with that among adults with continuous coverage (p<0.05). Longer disruptions among currently insured adults were significantly associated with worse care access, receipt, and affordability, with dose-response patterns. Currently uninsured adults, especially those with longer uninsured periods, reported significantly worse care access, receipt, and affordability than currently insured adults with coverage disruptions or continuous coverage. CONCLUSIONS Findings highlight the importance of continuous insurance coverage; disruptions owing to the COVID-19 pandemic will likely have adverse consequences for care access and affordability.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia.
| | - Jingxuan Zhao
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Michael T Halpern
- Division of Cancer Control & Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Stacey A Fedewa
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Leticia M Nogueira
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
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Ukhanova M, Marino M, Angier H, Jacob L, O'Malley J, Cottrell EK, Dambrun K, Heintzman J. The impact of capitated payment on preventive care utilization in community health clinics. Prev Med 2021; 145:106405. [PMID: 33388331 DOI: 10.1016/j.ypmed.2020.106405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 11/11/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
Only half of the United States population regularly receives recommended preventive care services. Alternative payment models (e.g., a per-member-per-month capitated payment model) may encourage the delivery of preventive services when compared to a fee-for-service visitbased model; however, evaluation is lacking in the United States. This study assesses the impact of implementing Oregon's Alternative Payment Methodology (APM) on orders for preventive services within community health centers (CHCs). This retrospective cohort study uses electronic health record data from the OCHIN, Inc., 2012-2018, analyzed in 2018-2019. Twenty-seven CHCs which implemented APM in 2013-2016 were compared to six non-APM CHCs. Clinic-level quarterly rates of ordering nine preventive services in 2012-2018 were calculated. For each phase and preventive service, we used difference-in-differences analysis to assess the APM impact on ordering preventive care. We found greater increases for APM CHCs compared to non-APM CHCs for orders of mammograms (difference-in-differences estimates (DDs) across four phases:1.69-2.45). Both groups had decreases in ordering cervical cancer screenings, however, APM CHCs had smaller decreases (DDs:1.62-1.93). The APM CHCs had significantly greater decreases in influenza vaccinations (DDs:0.17-0.32). There were no consistent significant differences in pre-post changes in APM vs. non-APM CHCs for cardiometabolic risk screenings, smoking status and depression assessments. There was nonsignificant change in the proportion of nontraditional encounters in APM clinics compared to controls. Transition from fee-for-service to an APM did not negatively impact delivery of preventive care. Further studies are needed to understand how to change encounter structures to best deliver recommended preventive care.
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Affiliation(s)
- Maria Ukhanova
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA.
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA; Department of Public Health and Preventive Medicine, Division of Biostatistics, Oregon Health and Science University, Portland, Oregon, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | - Erika K Cottrell
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA; OCHIN, Inc., Portland, Oregon, USA
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA; OCHIN, Inc., Portland, Oregon, USA
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Ukhanova MA, Tillotson CJ, Marino M, Huguet N, Quiñones AR, Hatch BA, Schmidt T, DeVoe JE. Uptake of Preventive Services Among Patients With and Without Multimorbidity. Am J Prev Med 2020; 59:621-629. [PMID: 32978012 PMCID: PMC7577968 DOI: 10.1016/j.amepre.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/12/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patients with multiple chronic conditions (multimorbidity) are seen commonly in primary care practices and often have suboptimal uptake of preventive care owing to competing treatment demands. The complexity of multimorbidity patterns and their impact on receiving preventive services is not fully understood. This study identifies multimorbidity combinations associated with low receipt of preventive services. METHODS This was a retrospective cohort study of U.S. community health center patients aged ≥19 years. Electronic health record data from 209 community health centers for the January 1, 2014-December 31, 2017 study period were analyzed in 2018-2019. Multimorbidity patterns included physical only, mental health only, and physical and mental health multimorbidity patterns, with no multimorbidity as a reference category. Electronic health record-based preventive ratios (number of months services were up-to-date/total months the patient was eligible for services) were calculated for the 14 preventive services. Negative binomial regression models assessed the relationship between multimorbidity physical and/or mental health patterns and the preventive ratio for each service. RESULTS There was a variation in receipt of preventive care between multimorbidity groups: individuals with mental health only multimorbidity were less likely to be up-to-date with cardiometabolic and cancer screenings than the no multimorbidity group or groups with physical health conditions, and the physical only multimorbidity group had low rates of depression screening. CONCLUSIONS This study provided critical insights into receipt of preventive service among adults with multimorbidity using a more precise method for measuring up-to-date preventive care delivery. Findings would be useful to identify target populations for future intervention programs to improve preventive care.
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Affiliation(s)
- Maria A Ukhanova
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.
| | | | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Division of Biostatistics, School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Brigit A Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Research Department, OCHIN Inc., Portland, Oregon
| | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Marchi KS, Dove MS, Heck KE, Fan C. The Affordable Care Act and Changes in Women's Health Insurance Coverage Before, During, and After Pregnancy in California. Public Health Rep 2020; 136:70-78. [PMID: 33108960 DOI: 10.1177/0033354920962798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Having health insurance is associated with improvements in health care access and use, health behaviors, and outcomes. We examined changes in health insurance coverage for California women before, during, and after pregnancy after implementation of the Affordable Care Act (ACA). METHODS We used data from the 2011-2017 California Maternal and Infant Health Assessment, an annual representative survey of women sampled from birth certificates (n = 47 487). We examined health insurance coverage at baseline before ACA implementation (2011-2013) and in each survey year from 2014 to 2017 for 3 periods (before, during, and after pregnancy). We calculated prevalence ratios to evaluate changes in health insurance coverage, adjusting for changes in demographic characteristics. Few women were uninsured during pregnancy before implementation of the ACA; therefore, analyses focused on health insurance before pregnancy and postpartum. RESULTS Before ACA implementation, 24.4% of women reported being uninsured before pregnancy, which decreased to 10.1% in 2017. About 17% of women reported being uninsured postpartum before ACA implementation, and this percentage decreased to 7.5% in 2017. ACA implementation resulted in a >50% adjusted decline in the likelihood of being uninsured before pregnancy or postpartum, primarily because of substantial increases in Medicaid coverage. CONCLUSIONS ACA implementation resulted in a dramatic reduction in mothers in California who were uninsured before and after pregnancy. Medicaid expansion played a major role in this improvement.
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Affiliation(s)
- Kristen S Marchi
- 8785 Center for Health Equity, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Melanie S Dove
- 8789 Division of Health Policy and Management, Department of Public Health Sciences, University of California, Davis, Davis, CA, USA
| | - Katherine E Heck
- 8785 Center for Health Equity, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Chuncui Fan
- 8785 Center for Health Equity, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
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10
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Jiang Y, Ni W. Impact of supplementary private health insurance on hospitalization and physical examination in China. CHINA ECONOMIC REVIEW 2020; 63:101514. [PMID: 35058675 PMCID: PMC7333596 DOI: 10.1016/j.chieco.2020.101514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 05/16/2020] [Accepted: 06/29/2020] [Indexed: 06/14/2023]
Abstract
Private health insurance (PHI) is considered an important supplement to the basic social health insurance schemes in the Chinese healthcare system. However, whether the strategy of engaging PHI as supplementary coverage is effective cannot be determined without knowing the impact of supplementary PHI on healthcare access and utilization, the evidence on which is currently absent in China. Therefore, we aimed to investigate the effects of supplementary PHI on hospitalization and physical examination to provide such evidence in the Chinese setting. We conducted a cross-sectional analysis using data from the 2015 wave of China Health and Retirement Longitudinal Study (CHARLS). Using probit models and bivariate probit models with instrumental variables (IVs), we evaluated the effects of supplementary PHI on the utilization of hospitalization and physical examination. Our analyses provided evidence that supplementary PHI increased the probability of physical examination but decreased that of hospitalization. Our findings suggest that supplementary PHI in China may effectively promote the use of high-value preventive care, thereby reducing subsequent utilization of expensive medical services. The present study provided preliminary evidence that the China healthcare system can benefit from engaging PHI as supplements to SHI.
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Affiliation(s)
- Yawen Jiang
- School of Public Health (Shenzhen), Sun Yat-sen University, Room 215, Mingde Garden #6, 132 East Outer Ring Road, Pan-yu District, Guangzhou, Guangdong, China
| | - Weiyi Ni
- Department of Pharmaceutical and Health Economics, University of Southern California, USC Schaeffer Center, 635 Downey Way, Verna & Peter Dauterive Hall (VPD) Suite 210, Los Angeles, CA 90089-3333, USA
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Yabroff KR, Reeder-Hayes K, Zhao J, Halpern MT, Lopez AM, Bernal-Mizrachi L, Collier AB, Neuner J, Phillips J, Blackstock W, Patel M. Health Insurance Coverage Disruptions and Cancer Care and Outcomes: Systematic Review of Published Research. J Natl Cancer Inst 2020; 112:671-687. [PMID: 32337585 PMCID: PMC7357319 DOI: 10.1093/jnci/djaa048] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/12/2020] [Accepted: 03/27/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival. METHODS We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively. RESULTS Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions. CONCLUSIONS Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Michael T Halpern
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Ana Maria Lopez
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Anderson B Collier
- Children’s Cancer Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Joan Neuner
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Manali Patel
- Stanford University School of Medicine, Stanford, CA, USA
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Park S, Chen J, Ma GX, Ortega AN. Utilization of essential preventive health services among Asians after the implementation of the preventive services provisions of the Affordable Care Act. Prev Med Rep 2019; 16:101008. [PMID: 31890468 PMCID: PMC6931224 DOI: 10.1016/j.pmedr.2019.101008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/11/2019] [Accepted: 10/20/2019] [Indexed: 11/22/2022] Open
Abstract
Utilization of cost-effective essential preventive health services increased after the implementation of the Affordable Care Act's (ACA) provision that non-grandfathered private insurers provide cost-effective preventive services without cost sharing in 2010. Little is known, however, whether this change is also observed among Asians in the US. We examined patterns of preventive services utilization among Asian subgroups relative to non-Latino whites (whites) after the implementation of the ACA's preventive services provisions. Using 2013-2016 Medical Expenditure Panel Survey data, we examined utilization trends in preventive services among Asian Indians, Chinese, Filipinos, and other Asians relative to whites. We also ran logistic regression models to estimate the likelihood of having received each of the seven essential preventive services (routine checkups, flu vaccinations, cholesterol screenings, blood pressure checkups, Papanicolaou "pap" tests, mammograms, and colorectal cancer screenings). Compared to whites, Asians had higher rates of utilization of routine checkups, cholesterol screenings, and flu vaccinations, but they had lower utilization rates of blood pressure checkups, pap tests, and mammograms. The patterns of preventive services utilization differed across the Asian subgroups. All Asian subgroups, except for Filipinos, were less likely to have pap tests or mammograms than whites. Moreover, we observed a decreasing trend in having pap tests, mammograms, or colorectal cancer screenings among all Asian subgroups between 2013 and 2016. Our findings suggest that there are low cancer screening rates across Asian subgroups. This indicates the need for programs tailored to specific Asian subgroups to improve cancer screening.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3125 Market Street, Nesbitt Hall 3rd Floor, Philadelphia, PA 19104, United States
| | - Jie Chen
- Department of Health Policy and Management, School of Public Health, University of Maryland, 4200 Valley Drive, Suite 2242, College Park, MD 20742, United States
| | - Grace X. Ma
- Department of Clinical Sciences and Center for Asian Health, Lewis Katz School of Medicine, Temple University, 3500 North Broad Street, Philadelphia, PA 19140, United States
| | - Alexander N. Ortega
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3125 Market Street, Nesbitt Hall 3rd Floor, Philadelphia, PA 19104, United States
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13
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Gaudette É, Pauley GC, Zissimopoulos JM. Lifetime Consequences of Early-Life and Midlife Access to Health Insurance: A Review. Med Care Res Rev 2018; 75:655-720. [PMID: 29166825 PMCID: PMC7081716 DOI: 10.1177/1077558717740444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Over the past decade, the number of studies examining the effects of health insurance has grown rapidly, along with the breadth of outcomes considered. In light of growing research in this area and the intense policy focus on coverage expansions in the United States, there is need for an up-to-date and comprehensive literature review and synthesis of lessons learned. We reviewed 112 experimental or quasi-experimental studies on the effects of health insurance prior to people becoming eligible for Medicare on a broad set of outcomes. Over the past decade, evidence related to the effect of increased access to health insurance has strengthened, illuminating that children and vulnerable adults are most likely to see health and economic benefits. We identified promising areas for future study in this active and burgeoning research area, noting benefit design of health insurance and outcomes such as government program participation and self-reported health status as targets.
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Affiliation(s)
| | - Gwyn C. Pauley
- University of Southern California, Los Angeles, CA, USA
- University of Wisconson, Madison, WI, USA
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14
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Singhal A, Damiano P, Sabik L. Medicaid Adult Dental Benefits Increase Use Of Dental Care, But Impact Of Expansion On Dental Services Use Was Mixed. Health Aff (Millwood) 2018; 36:723-732. [PMID: 28373339 DOI: 10.1377/hlthaff.2016.0877] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dental coverage for adult enrollees is an optional benefit under Medicaid. Thirty-one states and the District of Columbia have expanded eligibility for Medicaid under the Affordable Care Act. Millions of low-income adults have gained health care coverage and, in states offering dental benefits, oral health coverage as well. Using data for 2010 and 2014 from the Behavioral Risk Factor Surveillance System, we examined the impact of Medicaid adult dental coverage and eligibility expansions on low-income adults' use of dental care. We found that low-income adults in states that provided dental benefits beyond emergency-only coverage were more likely to have had a dental visit in the past year, compared to low-income adults in states without such benefits. Among states that provided dental benefits and expanded their Medicaid program, regression-based estimates suggest that childless adults had a significant increase (1.8 percentage points) in the likelihood of having had a dental visit, while parents had a significant decline (8.1 percentage points). One possible explanation for the disparity is that after expansion, newly enrolled childless adults might have exhausted the limited dental provider capacity that was available to parents before expansion. Additional policy-level efforts may be needed to expand the dental care delivery system's capacity.
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Affiliation(s)
- Astha Singhal
- Astha Singhal is an assistant professor of health policy and health services research at the Henry M. Goldman School of Dental Medicine at Boston University, in Massachusetts
| | - Peter Damiano
- Peter Damiano is a professor of preventive and community dentistry and director of the Public Policy Center at the University of Iowa, in Iowa
| | - Lindsay Sabik
- Lindsay Sabik is an associate professor of health policy and management at the University of Pittsburgh, in Pennsylvania
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15
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Brown CC, Tilford JM, Bird TM. Improved Health and Insurance Status Among Cigarette Smokers After Medicaid Expansion, 2011-2016. Public Health Rep 2018; 133:294-302. [PMID: 29620480 DOI: 10.1177/0033354918763169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The high concentration of smokers among subgroups targeted by the Affordable Care Act and the historically worse health and lower access to health care among smokers warrants an evaluation of how Medicaid expansion affects smokers. We evaluated the impact of Medicaid expansion on smoking behavior, access to health care, and health of low-income adults, and we compared outcomes of all low-income people with outcomes of low-income current smokers by states' Medicaid expansion status. METHODS We obtained data from the Behavioral Risk Factor Surveillance System (2011-2016) for low-income adults aged 18-64. We estimated multivariable linear ordinary least squares probability models using a quasi-experimental difference-in-difference approach to compare smoking behavior, access to health care, and health between people in expansion states and nonexpansion states and, specifically, on low-income adults and the subgroup of low-income current smokers. RESULTS Compared with low-income smokers in nonexpansion states, low-income smokers in expansion states were 7.6 percentage points (95% confidence interval [CI], 5.7-9.6; P < .001) more likely to have health insurance, 3.2 percentage points (95% CI, 1.3-5.2; P = .001) more likely to report good or better health, and 2.0 percentage points (95% CI, -3.9 to -0.1; P = .044) less likely to have cost-related barriers to care. Health and insurance gains among current smokers in expansion states were larger relative to health gains (1.6 percentage points; 95% CI, 0.5-2.7; P = .003) and insurance gains (4.6 percentage points; 95% CI, 3.5-5.8; P < .001) of all low-income adults in these states. CONCLUSIONS Greater improvements among low-income smokers in Medicaid expansion states compared with nonexpansion states could influence future smoking behaviors and warrant longer-term monitoring. Additionally, health and insurance gains among low-income smokers in expansion states suggest the potential for Medicaid expansion to improve health among smokers compared with nonsmokers.
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Affiliation(s)
- Clare C Brown
- 1 Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J Mick Tilford
- 1 Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - T Mac Bird
- 1 Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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16
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Daw JR, Sommers BD. Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes. JAMA 2018; 319:579-587. [PMID: 29450525 PMCID: PMC5838787 DOI: 10.1001/jama.2018.0030] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown. OBJECTIVE To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status. MAIN EXPOSURES The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years. MAIN OUTCOMES AND MEASURES Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission. RESULTS The study population included 1 379 005 births among women aged 24-25 years (exposure group; 299 024 in 2009; 1 079 981 in 2011-2013), and 1 551 192 births among women aged 27-28 years (control group; 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women. CONCLUSIONS AND RELEVANCE In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.
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Affiliation(s)
- Jamie R. Daw
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Health Policy and Economics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts
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17
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Venkataramani M, Pollack CE, Roberts ET. Spillover Effects of Adult Medicaid Expansions on Children's Use of Preventive Services. Pediatrics 2017; 140:peds.2017-0953. [PMID: 29133576 DOI: 10.1542/peds.2017-0953] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since the passage of the Affordable Care Act, Medicaid enrollment has increased by ∼17 million adults, including many low-income parents. One potentially important, but little studied, consequence of expanding health insurance for parents is its effect on children's receipt of preventive services. METHODS By using state Medicaid eligibility thresholds linked to the 2001-2013 Medical Expenditure Panel Surveys, we assessed the relationship between changes in adult Medicaid eligibility and children's likelihood of receiving annual well-child visits (WCVs). In instrumental variable analyses, we used these changes in Medicaid eligibility to estimate the relationship between parental enrollment in Medicaid and children's receipt of WCVs. RESULTS Our analytic sample consisted of 50 622 parent-child dyads in families with incomes <200% of the federal poverty level, surveyed from 2001 to 2013. On average, a 10-point increase in a state's parental Medicaid eligibility (measured relative to the federal poverty level) was associated with a 0.27 percentage point higher probability that a child received an annual WCV (95% confidence interval: 0.058 to 0.48 percentage points, P = .012). Instrumental variable analyses revealed that parental enrollment in Medicaid was associated with a 29 percentage point higher probability that their child received an annual WCV (95% confidence interval: 11 to 47 percentage points, P = .002). CONCLUSIONS In our study, we demonstrate that Medicaid expansions targeted at low-income adults are associated with increased receipt of recommended pediatric preventive care for their children. This finding reveals an important spillover effect of parental insurance coverage that should be considered in future policy decisions surrounding adult Medicaid eligibility.
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Affiliation(s)
- Maya Venkataramani
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Craig Evan Pollack
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Eric T Roberts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Teutsch SM, Glied S, Roy K. Strengthening the Use of Economics in Informing U.S. Public Health Policy. Am J Prev Med 2016; 50:S1-S3. [PMID: 27102852 PMCID: PMC8456754 DOI: 10.1016/j.amepre.2016.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 01/19/2016] [Accepted: 02/05/2016] [Indexed: 11/20/2022]
Affiliation(s)
- Steven M Teutsch
- Public Health Institute, Oakland, California; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California; Fielding School of Public Health, University of California, Los Angeles, California
| | - Sherry Glied
- Robert F. Wagner Graduate School of Public Service, New York University, New York, New York
| | - Kakoli Roy
- Policy Research, Analysis, and Development Office, Office of the Associate Director for Policy, CDC, Atlanta, Georgia.
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