The spillover effects of health insurance benefit mandates on public insurance coverage: Evidence from veterans

This study examines how regulations in private health insurance markets affect coverage of public insurance. We focus on mental health parity laws, which mandate private health insurance to provide equal coverage for mental and physical health services. The implementation of mental health parity laws may improve a quality dimension of private health insurance but at increased costs. We graphically develop a conceptual framework and then empirically examine whether the regulations shift individuals from private to public insurance. We exploit state-by-year variation in policy implementation in 1999–2008 and focus on a sample of veterans, who have better access to public insurance than non-veterans. Using data from the Current Population Survey, we find that the parity laws reduce employer-sponsored insurance (ESI) coverage by 2.1% points. The drop in ESI is largely offset by enrollment gains in public insurance, namely through the Veterans Affairs (VA) benefit and Medicaid/Medicare programs.     

Abortion laws into action: implementing legal reform

The worldwide trend towards liberalizing abortion laws has resulted in reduced abortion-related mortality in areas where legal abortion is accessible. In countries considering abortion reform, policy-makers and health care providers have a responsibility to ensure that provisions of any new law can be met. Preparations underway to prepare for South Africa's new abortion law can serve as a guideline for such action. A new abortion law calls for policy changes that may include 1) developing new standards, protocols, and guidelines for abortion care services; 2) ensuring provision of adequate trained staff willing to provide abortions; 3) streamlining administrative regulations to avoid delays; 4) establishing regulations and mechanisms for drug and equipment supply and distribution; 5) restructuring the health system to accommodate provision of abortion services; 6) allocating funds for new abortion services; and 7) reviewing and revising security measures. In addition, health professionals will require training in abortion provision, staff will need information updates about aspects of the legislation, and administrators and providers in a position to impede provision of services must be made aware of the affect of unsafe abortion on maternal health. Researchers should document the effect of the new law on women's health, the provision of reproductive health services, and the community. IEC (information, education, communication) activities will be required to inform the public about the new law and services, establish sex education programs in schools and health facilities, and mobilize family planning organizations and programs to help reduce the incidence of repeat abortions.     

Making abortions safe: a matter of good public health policy and practice

Globally, abortion mortality accounts for at least 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives. This article examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands the following: changes at national policy level; abortion training for service providers and the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.     

The role of law in public health: the case of family planning in the Philippines

Compared to neighboring countries, the Philippines has high fertility rates and a low prevalence of modern-method contraception use. The Philippine government faces political and cultural barriers to addressing family planning needs, but also legal barriers erected by its own policies. We conducted a review of laws and policies relating to family planning in the Philippines in order to examine how the law may facilitate or constrain service provision. The methodology consisted of three phases. First, we collected and analyzed laws and regulations relating to the delivery of family planning services. Second, we conducted a qualitative interview study. Third, we synthesized findings to formulate policy recommendations. We present a conceptual model for understanding the impact of law on public health and discuss findings in relation to the roles of health care provider regulation, drug regulation, tax law, trade policies, insurance law, and other laws on access to modern-method contraceptives.     

Abortion providers,professional identity,and restrictive laws: A qualitative study

Most studies on the impact of restrictive abortion laws have focused on patient-level outcomes. To better understand how such laws affect providers, we conducted a qualitative study of 27 abortion providers working under a restrictive law in North Carolina. Providers derived professional identity from their motivations, values, and experiences of pride related to abortion provision. The law affected their professional identities by perpetuating negative characterizations of their profession, requiring changes to patient care and communication, and creating conflicts between professional values and legal obligations. We conclude that a holistic understanding of the impact of abortion laws should include providers’ perspectives.     

Health system reform and safe abortion: A case study of Mongolia

Abstract

Unsafe abortion serves as a marker of global inequity as it is concentrated in the developing world where the poorest and most vulnerable women live. While liberalisation of abortion law is essential to the reduction of unsafe abortion, a number of challenges exist beyond this important step. This paper investigates how popular health system reforms consonant with neoliberal agendas can challenge access to safe abortion. We use Mongolia, a country that has liberalised abortion law, yet, limited access to safe abortion, as a case study. Mongolia embraced market reforms in 1990 and subsequently reformed its health system. We document how common reforms in the areas of finance and regulation can compromise the safety of abortions as they foster challenges that include inconsistencies in service delivery that further foment health inequities, adoption of reproductive health programmes that are incompatible with the local sociocultural context, unregulated growth of the private sector and poor enforcement of standards and technical guidelines for safe abortion. We then discuss how this case study suggests the conversations that reproductive health policy-makers must have with those engineering health sector reform to ensure access to safe abortion in a liberalised environment.     

社区卫生服务在突发公共卫生事件中的网底作用

经历“非典”和禽流感之后,政府和公众对突发公共卫生事件的认识普遍加强,特别是在管理层面的法律规定已经配套实施并逐步完善,社区卫生服务体系在突发公共卫生事件中所发挥的网底作用应当充分重视和强化。     

Moving from intersection to integration: public health law research and public health systems and services research

Context: For three decades, experts have been stressing the importance of law to the effective operation of public health systems. Most recently, in a 2011 report, the Institute of Medicine recommended a review of state and local public health laws to ensure appropriate authority for public health agencies; adequate access to legal counsel for public health agencies; evaluations of the health effects and costs associated with legislation, regulations, and policies; and enhancement of research methods to assess the strength of evidence regarding the health effects of public policies. These recommendations, and the continued interest in law as a determinant of health system performance, speak to the need for integrating the emerging fields of Public Health Law Research (PHLR) and Public Health Systems and Services Research (PHSSR). Methods: Expert commentary. Findings: This article sets out a unified framework for the two fields and a shared research agenda built around three broad inquiries: (1) the structural role of law in shaping the organization, powers, prerogatives, duties, and limitations of public health agencies and thereby their functioning and ultimately their impact on public health (“infrastructure”); (2) the mechanisms through which public health system characteristics influence the implementation of interventional public health laws (“implementation”); and (3) the individual and system characteristics that influence the ability of public health systems and their community partners to develop and secure enactment of legal initiatives to advance public health (“innovation”). Research to date has laid a foundation of evidence, but progress requires better and more accessible data, a new generation of researchers comfortable in both law and health research, and more rigorous methods. Conclusions: The routine integration of law as a salient factor in broader PHSSR studies of public health system functioning and health outcomes will enhance the usefulness of research in supporting practice and the long‐term improvement of system performance.     

Incoherent policies on universal coverage of health insurance and promotion of international trade in health services in Thailand

The Thai government has implemented universal coverage of health insurance since October 2001. Universal access to antiretroviral (ARV) drugs has also been included since October 2003. These two policies have greatly increased the demand for health services and human resources for health, particularly among public health care providers. After the 1997 economic crisis, private health care providers, with the support of the government, embarked on new marketing strategies targeted at attracting foreign patients. Consequently, increasing numbers of foreign patients are visiting Thailand to seek medical care. In addition, the economic recovery since 2001 has greatly increased the demand for private health services among the Thai population. The increasing demand and much higher financial incentives from urban private providers have attracted health personnel, particularly medical doctors, from rural public health care facilities. Responding to this increasing demand and internal brain drain, in mid-2004 the Thai government approved the increased production of medical doctors by 10,678 in the following 15 years. Many additional financial incentives have also been applied. However, the immediate shortage of human resources needs to be addressed competently and urgently. Equity in health care access under this situation of competing demands from dual track policies is a challenge to policy makers and analysts. This paper summarizes the situation and trends as well as the responses by the Thai government. Both supply and demand side responses are described, and some solutions to restore equity in health care access are proposed.     

Public Health Law and the Prevention and Control of Obesity

Context: Obesity constitutes a major public health challenge in the United States. Obesogenic environments have increased owing to the consumption of calorie-dense foods of low nutritional value and the reduction of daily physical activity (e.g., increased portion sizes of meals eaten in and out of the home and fewer physical activity requirements in schools). Policymakers and public health practitioners need to know the best practices and have the competencies to use laws and legal authorities to reverse the obesity epidemic. For instance, statutes and regulations at the federal, state, and local levels of government have been implemented to improve nutritional choices and access to healthy foods, encourage physical activity, and educate consumers about adopting healthy lifestyles.Methods: In an effort to understand the application of laws and legal authorities for obesity prevention and control, in June 2008 the Centers for Disease Control and Prevention convened the National Summit on Legal Preparedness for Obesity Prevention and Control. An outcome of this summit will be the publication of the proceeding''s white papers written by eight law and subject-matter experts with substantive contributions from summit participants, which will identify actionable options that sectors and organizations at various jurisdictional levels can consider adopting.Findings: Law has played a critical role in the control of chronic diseases and the behaviors that lead to them. The use of a systematic legal framework—the use of legislation, regulation, and policy to address the multiple factors that contribute to obesogenic environments—can assist in the development, implementation, and evaluation of a variety of legal approaches for obesity prevention and control.Conclusions: Although public health–focused legal interventions are in an early stage and the direct and indirect impact they may have on the obesity epidemic is not yet understood, efforts such as the summit and white papers should help determine potentially viable legal interventions and assess their impact on population-level change.     

The decriminalisation of abortion in Colombia as cautionary tale. Social movements,numbers and socio-technical struggles in the promotion of health as a right

ABSTRACT

This paper discusses the complexity of contemporary struggles for collective health in Colombia, by analysing the efforts of different actors to inscribe abortion as a matter of public health and as a human right. In 2006 the Colombian Constitutional Court (Sentence C 355 of 2006) partially decriminalised abortion in specific circumstances. Such a change in regulation was the result of the strategic coordination of international organisations, researchers and women’s social movements. These groups produced a powerful network of international regulation and epidemiological data about abortion’s mortality and burden of disease in order to move the discussion from the moral field to public health and international law. Despite the significance of the sentence in terms of civil rights, ten years after the regulation there is no clarity about its impact. Conservative sectors within the government have limited the operation of the regulation, through eliciting convoluted rules for hospitals and care providers. On the other hand, data about safe abortions are weak and precarious. Recently groups opposed of abortion have exploited such weakness to undermine the impact of the decriminalisation and to criticise the justification of legalising abortion as a matter of public health.     

After After Tiller: the impact of a documentary film on understandings of third-trimester abortion

Onscreen pseudo-experiences have been shown to influence public perceptions of contested social issues. However, research has not considered whether such experiences have limits in their influence and/or vary in their impact. Using the case of third-trimester abortion, an issue subject to high amounts of misinformation, low public support and low occurrence in the general population, we investigate how the pseudo-experience of viewing After Tiller, a documentary film showing stories of third-trimester abortion, providers and patients, might serve as a counterpoint to misinformation and myth. We interviewed 49 viewers to assess how viewing the film interacted with viewers’ previously held understandings of later abortion. Participants reported that viewing made them feel more knowledgeable about later-abortion patients and providers and increased their support for legal third-trimester abortion access, suggesting the efficacy of this pseudo-experience in changing belief. Nonetheless, respondents’ belief systems were not entirely remade and the effects of the film varied, particularly in regards to gatekeeping around the procedure and the reasons why women seek later abortion. Findings show the potential of onscreen pseudo-experiences as a means for social change, but also reveal their limits and varying impacts.     

政府在保障农民健康领域的职能定位

“医改”的终极目标是实现全民健康保障。从5个方面详细阐述政府在保障农民健康领域的职能定位:农村公共卫生服务的供给;直接举办部分农村公立医疗机构;组织和建立新型农村医疗保障制度;农村卫生资源和技术准入规划和控制;依法加强对农村医药卫生市场的监管。     

“Yo No Sabía...”—Immigrant Women’s Use of National Health Systems for Reproductive and Abortion Care

Half of pregnancies worldwide are unintended; half of these end in abortion. Immigrant women encounter more obstacles to reproductive healthcare than non-immigrant women, and access to national healthcare is a particularly important factor in abortion access. Spain’s government recently liberalized abortion laws, including abortion services in the national health system available to immigrants. Evidence suggests that immigrant women in Spain experience difficulties navigating the health system—the impact of the changed abortion laws on immigrant’s women’s access to care is not yet clear. Through a literature review and analysis, this paper examines the experiences of immigrant women with national health systems, and their use of such systems for reproductive and abortion care, in order to explore what could be expected in Spain as the national health system expands to include abortion care, and to illuminate immigrant women’s experiences with using national health systems for reproductive healthcare more broadly.     

公共卫生医师定位的思考

公共卫生医师是我国法定的四类医师之一,但其内涵定位尚未形成共识。存在的主要问题是把公共卫生医师与执行公共卫生任务的工作人员混为一谈,未明确公共卫生医师与临床医师的关系以及处方权内涵,公共卫生教育、相关法规存在局限性。公共卫生医师定位为针对群体健康相关问题开展监测、调查、评估和干预的专业技术人员。建议保留公共卫生医师执业资格,突出公共卫生医师针对群体健康开具大处方的属性,鼓励公共卫生医师获取临床医师执业资格,针对个体开具处方,鼓励临床医师获取公共卫生医师执业资格,改进公共卫生院校教育,试点公共卫生医师规范化培训,培养"防治结合"的医师。     

Determinants of elders' choice between private and public health care providers

OBJECTIVE: Elderly choose between utilizing private or public health care providers based on their socioeconomic, demographic, and epidemiological condition. The purposes of this study was to evaluate how these factors affect the choice of health care provider and to compare the impact of their choice on individual and family income. METHODS: Data from 7,920 elders interviewed in a study of the State Committee for the Elderly of the state of Rio Grande do Sul in 1995 was used to evaluate the impact of elders' gender, age, educational level, individual income, family income, family size, participation in the family total income, and health self-assessment when choosing private or public health care providers. The statistical analysis was carried out using logistic regression. RESULTS: To have access to private health care providers, family income had a much more significant impact than individual income. When family income increased in one minimum wage, the odds of using private providers increased by 20% while it was only 7% when there was a similar increase in individual income. Other variables had also a positive impact: female, age, schooling, and smaller family size. CONCLUSIONS: Elderly choices' on health care depend on the family's needs and resources and not on the individual's condition. Therefore, low-income elderly health is a lower priority in the family and it is disproportionately impaired by reduced family resources and deficiencies of public health care.     

Capacity constraints and time allocation in public health clinics

Unlike in the production of most goods, changes in capacity for labor‐intensive services only affect outcomes of interest insofar as service providers change the way they allocate their time in response to those capacity changes. In this paper, we examine how public sector service providers respond to unexpected capacity constraints in the specific context of public health clinics. We exploit an exogenous reduction in public health clinic capacity to quantify the trade‐off between patients treated and time spent with each patient, which we treat as a proxy for a quality versus quantity decision. We provide evidence that these small and generally insignificant effects on nurse time favor public sector employees prioritizing quality of each interaction over clearing the patient queue.     

初产前人工流产对再次妊娠女性健康的影响

目的:探讨人工流产特别是初产前人工流产对再次妊娠女性健康的影响。方法:采用回顾性队列研究法,将2003年5~11月住院分娩的单胎初产妇按照有无人工流产史分为人流组和非人流组,于产后第2天对其进行问卷调查并摘录住院病例。结果:前置胎盘、分娩期胎盘并发症(包括胎盘粘连、残留、植入)、第三产程延长以及产后出血的比例,人工流产组均高于非人工流产组,两组间差异有统计学意义。因子分析和多因素非条件Logistic回归分析显示,人工流产高危行为(包括人工流产史、人工流产数、末次人流与本次妊娠的时间间隔)会使第三产程延长的风险增加。结论:初产前人工流产对再次妊娠时女性健康的影响较大,应采取科学有效的措施降低人工流产率,促进女性健康。     

Do they work? Regulating for-profit providers in Zimbabwe

The experience of low- and middle-income countries (LMC) with respect to regulation and legislation in the health sector is in marked contrast to that of Canada and Europe. It is suggested that the degree to which regulatory mechanisms can influence private sector activity in LMC is quite low. However, there has been little work done on exploring just how, and to what extent, these regulations fail. Through the use of stakeholder interviews, this study explored the effectiveness of regulations directed at the private-for-profit sector (general practitioners, private clinics and hospitals) in Zimbabwe. The study found that there was limited and asymmetric knowledge of basic regulations among government bodies and private providers. However, there was a clear feeling that regulations are not being implemented and enforced effectively. A variety of opportunistic practices have been observed among private providers, including: practices of self-referral, where patients are sent to other services the provider has a financial interest in; over-servicing; doctor-patient collusion to collect health insurance payments; and the use of unlicensed staff in private facilities. Key factors limiting effectiveness of regulation in the health sector include the over-centralization and lack of independence of the regulatory body, the absence of legal mechanisms to control the price of care, and the lack of knowledge by patients of their rights. The study also identified a number of potential strategies for improving the current regulatory environment. For example, in order to improve monitoring, 'informal' arrangements between the centralized regulatory body and local authorities developed. There is a need to develop ways to formalize the role of these authorities. In addition, professional associations of private providers are also identified as key players through which to improve the impact of regulation among private providers. Increasing consumer access to information and knowledge is another potential way to improve information within the regulatory process as well as implementation.