Health insurance coverage and access to child and maternal health services in West Africa: a systematic scoping review

BACKGROUND

According to the United Nations, the third Sustainable Development Goal, 'Ensure Healthy Lives and Promote Well-Being at All Ages', set numerous targets on child and maternal health. Universal health insurance is broadly seen as a solution to fulfil these targets. West Africa is known to have the most severe maternal mortality and under-five mortality rates in the world. This review seeks to understand whether health insurance provides increased access to services for mothers and children in this region.

METHODS

The protocol for this review is registered in the International Prospective Register of Systematic Reviews database (CRD42020203859). A search was conducted in the MEDLINE Complete, Embase, CINAHL Complete and Global Health databases. Eligible studies were from West African countries. The population of interest was mothers and children and the outcome of interest was the impact of health insurance on access to services. Data were extracted using a standardized form. The primary outcome was the impact of health insurance on the rate of utilization and access to services. The Joanna Briggs Institute Critical Appraisal Tool was used for methodological assessment.

RESULTS

Following screening, we retained 49 studies representing 51 study settings. In most study settings, health insurance increased access to child and maternal health services. Other determinants of access were socio-economic factors such as wealth and education.

CONCLUSIONS

Our findings suggest that health insurance may be a viable long-term strategy to alleviate West Africa's burden of high maternal and child mortality rates. An equity lens must guide future policy developments and significant research is needed to determine how to provide access reliably and sustainably to services for mothers and children in the near and long term.

Examining the Effectiveness of Financial Protection Schemes in Reducing Health Inequality

Health protection schemes such as health insurance and financial assistance provide immense help and support to access health care services, especially to the poor and marginalized section of society. India is witness to low health-related expenditure, and the society's socioeconomic and demographic structure further drops health care access to the new bottom. Consequently, inequality in health care access is highly observed across many socioeconomic attributes. The condition of Bihar, the poorest state of India, is more alarming. The analysis suggests that financial support in terms of universal health insurance coverage considerably reduces out-of-pocket expenditure and thus health inequality. Further, the low health insurance coverage is not solely due to a lack of institutional commitment and implementation process; the cognitive behavior and attitude of people are equally responsible for low health care access. An intensive awareness program to show the benefit of the health insurance scheme and sensitization of people against the social stigma is important to provide better health care access and reduce health inequality.

Testing for Hepatitis C During Pregnancy Among Persons With Medicaid and Commercial Insurance: Cohort Study

BACKGROUND

The reported incidence of acute hepatitis C virus (HCV) infection is increasing among persons of childbearing age in the United States. Infants born to pregnant persons with HCV infection are at risk for perinatal HCV acquisition. In 2020, the United States Preventive Services Task Force and Centers for Disease Control and Prevention recommended that all pregnant persons be screened during each pregnancy for hepatitis C. However, there are limited data on trends in hepatitis C testing during pregnancy.

OBJECTIVE

We estimated hepatitis C testing rates in a large cohort of patients with Medicaid and commercial insurance who gave birth during 2015-2019 and described demographic and risk-based factors associated with testing.

METHODS

Medicaid and commercial insurance claims for patients aged 15-44 years and who gave birth between 2015 and 2019 were included. Birth claims were identified using procedure and diagnosis codes for vaginal or cesarean delivery. Hepatitis C testing was defined as an insurance claim during the 42 weeks before delivery. Testing rates were calculated among patients who delivered and among the subset of patients who were continuously enrolled for 42 weeks before delivery. We also compared the timing of testing relative to delivery among patients with commercial or Medicaid insurance. Multivariable logistic regression was used to identify factors associated with testing.

RESULTS

Among 1,142,770 Medicaid patients and 1,207,132 commercially insured patients, 175,223 (15.3%) and 221,436 (18.3%) were tested for hepatitis C during pregnancy, respectively. Testing rates were 89,730 (21.8%) and 187,819 (21.9%) among continuously enrolled Medicaid and commercially insured patients, respectively. Rates increased from 2015 through 2019 among Medicaid (from 20,758/108,332, 19.2% to 13,971/52,330, 26.8%) and commercially insured patients (from 38,308/211,555, 18.1% to 39,152/139,972, 28%), respectively. Among Medicaid patients, non-Hispanic Black (odds ratio 0.73, 95% CI 0.71-0.74) and Hispanic (odds ratio 0.53, 95% CI 0.51-0.56) race or ethnicity were associated with lower odds of testing. Opioid use disorder, HIV infection, and high-risk pregnancy were associated with higher odds of testing in both Medicaid and commercially insured patients.

CONCLUSIONS

Hepatitis C testing during pregnancy increased from 2015 through 2019 among patients with Medicaid and commercial insurance, although tremendous opportunity for improvement remains. Interventions to increase testing among pregnant persons are needed.

Early changes in health coverage and access to dental care associated with Medicaid expansion under the COVID-19 pandemic

The extent to which the COVID-19 pandemic has affected early changes in health coverage and access to dental care services in states that expanded Medicaid versus those that did not is currently not well known. Using data from the National Health Interview Survey, we found that, during the first year of the COVID-19 pandemic, states that had previously expanded their Medicaid programs under the Affordable Care Act had lower uninsurance rates for White low-income adults (-8.8 percentage points; 95% CI: -16.6, -1.0) and lower dental uninsurance rates for all low-income adults (-5.4 percentage points; 95% CI: -10.4, -0.5). Our findings also suggest that the combination of Medicaid expansion with coverage of adult dental benefits in Medicaid was associated with improved dental coverage and access to dental care during the pandemic. With the expiration of the public health emergency declaration, states are considering strategies to prevent disruptions in Medicaid coverage. Our study adds to the evidence of the importance of Medicaid expansion in stabilizing health coverage during a public health crisis.

Analysis of predictors of malnutrition in adult hospitalized patients: social determinants and food security

Background

Malnutrition in hospitalized patients is becoming a priority during the patient care process due to its implications for worsening health outcomes. It can be the result of numerous social factors beyond clinical ones. This study aimed to evaluate the link between these various risk factors considered social determinants of health, food security levels, and malnutrition and to identify potential predictors.

Methods

A cross-sectional observational study was conducted on a random sample of adult patients in five different hospitals in Lebanon. Malnutrition was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Patients were interviewed to collect social and economic characteristics and were categorized into four criteria: (1) area of residence (urbanization level), (2) level of education, (3) employment status, and (4) source of health coverage. The food security level was screened by a validated two-question tool, adapted from the US Department of Agriculture Household Food Security Survey, targeting both quantity and quality.

Results

In a random sample of 343 patients, the prevalence of malnutrition according to the GLIM criteria was 35.6%. Patients with low levels of food security, mainly low quality of food, had higher odds of being malnourished (OR = 2.93). Unemployed or retired patients and those who have only completed only elementary school had higher odds of being diagnosed with malnutrition as compared to those who were employed or had university degrees, respectively (OR = 4.11 and OR = 2.33, respectively). Employment status, education level, and type of health coverage were identified as predictors of malnutrition in the multiple regression model. Household location (urban vs. rural) was not associated with malnutrition.

Conclusion

The social determinants of health identified in our study, mainly the level of education and income level, in addition to food security, were identified as predictors of malnutrition in hospitalized patients. These findings should guide healthcare professionals and national policies to adopt a broader perspective in targeting malnutrition by including social determinants in their nutrition care.

Consequences of India's population aging to its healthcare financing and provision

OBJECTIVES

To conduct a comprehensive literature review on the state of population aging, healthcare financing, and provision in India.

METHODS

To obtain relevant records in the Indian context, multiple publications were searched from databases, such as Scopus, ScienceDirect, Web of Science, Medline/PubMed, JSTOR, and Google Scholar using the following keywords: "Population Ageing," "Population Aging," "Health System," "Demographic Dividend," "Non-communicable Diseases," "Double Burden of Diseases," "Health Spending," "Sustainable Health Financing," and "Health Coverage." Data on different health indices were collected from different websites of the government of India and international organizations (e.g. World Bank, UN, WHO, and Statista).

RESULTS

As people live longer, India faces a double burden of disease, with the rising incidence of non-communicable diseases (NCDs) amidst the presence of widespread communicable diseases. The combined problem of the double burden of diseases and population aging poses a severe sustainability challenge for its healthcare financing and the entire health system. Healthcare financing based on progressive taxation and large-scale prepayment coverage is an effective solution for sustaining the health system. However, due to the prevalence of indirect taxes, India's tax system is regressive. Hence, community-based health insurance (CBHI) schemes can be a feasible solution to cover the large mass of poor working in the informal sector.

CONCLUSIONS

India needs to address the alterations in its healthcare needs and demands brought on by the advancing demographic shift. To achieve so, the country's healthcare system must be reformed to accommodate strong national policies focusing on universal access to critical care especially geriatric and palliative care.

Medicare Opt-Out Trends Among Dermatologists May Reflect Systemic Health Policy: Cross-sectional Analysis

BACKGROUND

Provider opt-out of accepting Medicare insurance is a nationally tracked metric by the Centers for Medicare & Medicaid Services (CMS) for all physicians, including dermatologists. Although this usually only consists of a small number of providers, the magnitude of opting out has varied historically, often tracing changes in systemic health care policy.

OBJECTIVE

In this paper, we explored dermatologist opt-out data since 2001, as reported by the CMS, to characterize trends and provide evidence that shifts in provider opt-out may represent a potential indicator of the state of health policy and possible needs for reform as it pertains to Medicare.

METHODS

The publicly available Opt Out Affidavits data set, available from the CMS, was evaluated for providers in all dermatologic specialties from January 1, 2001, to May 27, 2022.

RESULTS

There were a total of 196 dermatology opt-outs in the overall period, with the largest spike being 33 providers in 2016, followed by generally consistent decreases through 2021. In the most recent 12 months of data, the number of new monthly opt-outs from January 2022 to May 2022 was significantly higher than that of the trailing 7 months of 2021 (P=.03).

CONCLUSIONS

Despite decreasing numbers of dermatologist opt-outs in the late-2010s, 2022 was marked by a significant increase in opt-outs. The reduced acceptance of Medicare by dermatologists may present risks to care access, so it is important to frequently assess physician opt-out data and changes over time.

Melanoma Identification and Management in an Unsheltered Male Using Teledermatology: Street Medicine Perspective

Skin cancers are concerning for unsheltered people experiencing homelessness because of their high levels of sun exposure. Currently, there is little data on the prevalence of skin cancers in people experiencing homelessness. Skin diseases are often untreated in people experiencing homelessness due to a lack of access to specialized care. Miami Street Medicine (MSM) is an organization that provides people experiencing homelessness in the Miami Health District with medical care in a nonclinical street setting, near overpasses, sidewalks, and encampments. We present a case of an unsheltered 59-year-old male with a pigmented, 2 cm × 2 cm facial lesion that developed over several years. Through a teledermatology consultation, his lesion was highly suspicious of melanoma and further evaluation was recommended. Due to a lack of insurance, he could not be treated at any dermatology clinic. Coincidentally, 2 weeks later, he developed cellulitis of his lower extremity and was admitted to the local safety-net hospital through the emergency department. By coordinating with his primary inpatient team, MSM was able to include a biopsy of the lesion as part of his hospital stay. The results demonstrated melanoma in situ. The vital course of action was to ensure treatment before metastasis. After registration for insurance and follow-up with a surgical oncology team, he is weeks away from excision and reconstruction surgery. His unsheltered status made follow-up difficult, but MSM bridged the gap from the street to the clinical setting by incorporating teledermatology into patient evaluations and leveraging connections with community shareholders such as charitable clinics and volunteer physicians. This case also represents the barriers to care for cancer-based dermatologic outreach among people experiencing homelessness.

Role of User Benefit Awareness in Health Coverage Utilization among the Poor in Cambodia

The objective of this study was to understand the steps to health coverage benefit utilization in Cambodia toward improving access to health care and financial risk protection for the poor. We particularly examine the role of user awareness in the pathway to care seeking and benefit utilization with respect to the Health Equity Funds (HEF). Using 2016 survey data that were nationally representative of households with children under two years of age, we used a series of logistic regression models to evaluate associations between respondents' awareness of benefits, public health care seeking behaviors, coverage benefit claims, and out-of-pocket expenditures. Beneficiaries were generally aware of their entitlements, although their awareness of specific benefits, such as transport reimbursement, was relatively lower. Awareness of free services at public health centers was associated with twice the odds of having ever visited a public provider for outpatient care, while awareness of free services at public hospitals was associated with higher odds of always seeking inpatient care in the public sector. Study findings point to the decision of where to seek care as the critical point in the pathway to HEF utilization. If the decision had already been made to go to a public provider, it was likely that HEF benefits were claimed. Interventions that prompt appropriate care seeking in the public sector may do the most to improve HEF utilization and subsequently improve access to care through sufficient financial risk protection.

Health insurance, pediatric asthma, and emergency department usage

This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10 years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.

Mapping Research Trends of Universal Health Coverage From 1990 to 2019: Bibliometric Analysis

Background

Universal health coverage (UHC) is one of many ambitious, health-related, sustainable development goals. Sharing various experiences of achieving UHC, in terms of challenges, pitfalls, and future prospects, can help policy and decision-makers reduce the likelihood of committing errors. As such, scholarly articles and technical reports are of paramount importance in shedding light on the determinants that make it possible to achieve UHC.

Objective

The purpose of this study is to conduct a comprehensive analysis of UHC-related scientific literature from 1990 to 2019.

Methods

We carried out a bibliometric analysis of papers related to UHC published from January 1990 to September 2019 and indexed in Scopus via VOSviewer (version 1.6.13; CWTS). Relevant information was extracted: the number of papers published, the 20 authors with the highest number of publications in the field of UHC, the 20 journals with the highest number of publications related to UHC, the 20 most active funding sources for UHC-related research, the 20 institutes and research centers that have produced the highest number of UHC-related research papers, the 20 countries that contributed the most to the research field of UHC, the 20 most cited papers, and the latest available impact factors of journals in 2018 that included the UHC-related items under investigation.

Results

In our analysis, 7224 articles were included. The publication trend was increasing, showing high interest in the scientific community. Most researchers were from the United States, the United Kingdom, and Canada, with Thailand being a notable exception. The Lancet accounted for 3.95% of published UHC-related research. Among the top 20 funding sources, the World Health Organization (WHO), the Bill and Melinda Gates Foundation, and the National Institutes of Health (NIH) accounted for 1.41%, 1.34%, and 1.02% of published UHC-related research, respectively. The highest number of citations was found for articles published in The Lancet, the American Journal of Psychiatry, and the Journal of the American Medical Association (JAMA). The top keywords were “health insurance,” “insurance,” “healthcare policy,” “healthcare delivery,” “economics,” “priority,” “healthcare cost,” “organization and management,” “health services accessibility,” “reform,” “public health,” and “health policy.”

Conclusions

The findings of our study showed an increasing scholarly interest in UHC and related issues. However, most research concentrated in middle- and high-income regions and countries. Therefore, research in low-income countries should be promoted and supported, as this could enable a better understanding of the determinants of the barriers and obstacles to UHC achievement and improve global health.

Moderate Effects of Same-Sex Legislation on Dependent Employer-Based Insurance Coverage Among Sexual Minorities

A difference-in-difference approach was used to compare the effects of same-sex domestic partnership, civil union, and marriage policies on same- and different-sex partners who could have benefitted from their partners' employer-based insurance (EBI) coverage. Same-sex partners had 78% lower odds (Marginal Effect = -21%) of having EBI compared with different-sex partners, adjusting for socioeconomic and health-related factors. Same-sex partners living in states that recognized same-sex marriage or domestic partnership had 89% greater odds of having EBI compared with those in states that did not recognize same-sex unions (ME = 5%). The impact of same-sex legislation on increasing take-up of dependent EBI coverage among lesbians, gay men, and bisexual individuals was modest, and domestic partnership legislation was equally as effective as same-sex marriage in increasing same-sex partner EBI coverage. Extending dependent EBI coverage to same-sex partners can mitigate gaps in coverage for a segment of the lesbians, gay men, and bisexual population but will not eliminate them.

Dengue and health care access: the role of social determinants of health in dengue surveillance in Colombia

Based on a first-hand experience from Colombia in the context of a local dengue research project, this paper illustrates how social determinants of health are associated with public health and how they can affect disease surveillance systems. The paper shows how various issues related to dengue case notification procedures and health insurance systems in Colombia are intertwined with more structural socio-economic factors. We argue that there is a need for public health interventions and health related research to acknowledge and consider the important role social determinants play in public health dynamics.

Global health: the importance of evidence-based medicine

Global health is a varied field that comprises research, evaluation and policy that, by its definition, also occurs in disparate locations across the world. This forum article is introduced by our guest editor of the Medicine for Global Health article collection, Gretchen Birbeck. Here, experts based across different settings describe their personal experiences of global health, discussing how evidence-based medicine in resource-limited settings can be translated into improved health outcomes.

Massachusetts health reform and disparities in coverage, access and health status

BACKGROUND

Massachusetts health reform has achieved near-universal insurance coverage, yet little is known about the effects of this legislation on disparities.

OBJECTIVE

Since racial/ethnic minorities and low-income individuals are over-represented among the uninsured, we assessed the effects of health reform on disparities.

DESIGN

Cross-sectional survey data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 2006-2008.

PARTICIPANTS

Adults from Massachusetts (n = 36,505) and other New England states (n = 63,263).

MAIN MEASURES

Self-reported health coverage, inability to obtain care due to cost, access to a personal doctor, and health status. To control for trends unrelated to reform, we compared adults in Massachusetts to those in all other New England states using multivariate logistic regression models to calculate adjusted predicted probabilities.

KEY RESULTS

Overall, the adjusted predicted probability of health coverage in Massachusetts rose from 94.7% in 2006 to 97.7% in 2008, whereas coverage in New England remained around 92% (p < 0.001 for difference-in-difference). While cost-related barriers were reduced in Massachusetts, there were no improvements in access to a personal doctor or health status. Although there were improvements in coverage and cost-related barriers for some disadvantaged groups relative to trends in New England, there was no narrowing of disparities in large part because of comparable or larger improvements among whites and the non-poor.

CONCLUSIONS

Achieving equity in health and health care may require additional focused intervention beyond health reform.