Gendering the migraine market: do representations of illness matter?

Migraine is a common, debilitating and costly disorder. Yet help-seeking for and rates of diagnosis of migraine are low. Drawing on ethnographic observations of pharmaceutical marketing practices at professional headache conferences and a content analysis of migraine advertising, principally in the USA, this paper demonstrates: (1) that the pharmaceutical industry directs its marketing of migraine medication to women; and (2) as part of this strategy, pharmaceutical advertisements portray women as the prototypical migraine sufferer, through representations that elicit hegemonic femininity. This strategy creates the impression that migraine is a "women's disorder", which, in turn, exacerbates gender bias in help seeking and diagnosis of migraine and reifies presumptions about the epidemiology of the disorder. I conclude that these pharmaceutical marketing practices have a paradoxical effect: even as they educate and raise awareness about migraine, they also create barriers to help seeking and diagnosis.     

Public and private health insurance premiums: how do they affect the health insurance status of low-income childless adults?

The Patient Protection and Affordable Care Act (ACA) will substantially increase public health insurance eligibility and alter the costs of insurance coverage. Using Current Population Survey (CPS) data from the period 2000-2008, we examine the effects of public and private health insurance premiums on the insurance status of low-income childless adults, a population substantially affected by the ACA. Results show higher public premiums to be associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured, while increased private premiums decrease the probability of having private insurance. Eligibility for premium assistance programs and increased subsidy levels are associated with lower rates of uninsurance. The magnitudes of the effects are quite modest and provide important implications for insurance expansions for childless adults under the ACA.     

How do health insurance loading fees vary by group size?: implications for Healthcare reform

The health insurance loading fee represents the portion of the premium above the expected amount of medical care expenditures paid by the insurance company. The size of the loading fees and how they vary by employer group size have important implications for health policy given the recent passage of the Patient Protection and Affordable Care Act. Despite their policy relevance, there is surprisingly little empirical evidence on the magnitude and the determinants of health insurance loading fees. This paper provides estimates of the loading fees by firm size using data from the confidential Medical Expenditure Panel Survey Household Component–Insurance Component Linked File. Overall, we find an inverse relationship between employer group size and loading fees. Firms of up to 100 employees face similar loading fees of approximately 34%. Loads decline with firm size and are estimated to be on average 15% for firms with more than 100 employees, but less than 10,000 employees, and 4% for firms with more than 10,000 workers.     

Relationship status and health: Does the use of different relationship indicators matter?

Studies that analyse the association between relationship status and health usually disregard non-marital relationships. The present study examines if the use of different relationship indicators leads to different associations between relationship status and physical and mental health. The database used for this analysis is the Survey of Health and Ageing in Europe, a large population-based survey of Europeans aged 50 and over and their cohabitants. This study combines cross-sectional and retrospective data of 13 European countries. The sample size is 9298 men and 11,631 women for grip strength and 9609 men and 12,333 women for depression. Generalised estimating equations are used. For men, the goodness-of-fit measure quasi-likelihood under the independence model criterion indicates that marital status is a better predictor than cohabitation status or partnership status for predicting grip strength. However, for grip strength of women, there are only small differences in the model fit between the different relationship indicators. For both men and women, the partnership status (marriage, cohabitation or dating relationship) shows the best model fit for explaining depression. The results suggest that future health research could benefit from the use of relationship indicators other than marital status, particularly regarding mental health.     

How can the regulator show evidence of (no) risk selection in health insurance markets? Conceptual framework and empirical evidence

If consumers have a choice of health plan, risk selection is often a serious problem (e.g., as in Germany, Israel, the Netherlands, the United States of America, and Switzerland). Risk selection may threaten the quality of care for chronically ill people, and may reduce the affordability and efficiency of healthcare. Therefore, an important question is: how can the regulator show evidence of (no) risk selection? Although this seems easy, showing such evidence is not straightforward. The novelty of this paper is two-fold. First, we provide a conceptual framework for showing evidence of risk selection in competitive health insurance markets. It is not easy to disentangle risk selection and the insurers’ efficiency. We suggest two methods to measure risk selection that are not biased by the insurers’ efficiency. Because these measures underestimate the true risk selection, we also provide a list of signals of selection that can be measured and that, in particular in combination, can show evidence of risk selection. It is impossible to show the absence of risk selection. Second, we empirically measure risk selection among the switchers, taking into account the insurers’ efficiency. Based on 2-year administrative data on healthcare expenses and risk characteristics of nearly all individuals with basic health insurance in the Netherlands (N > 16 million) we find significant risk selection for most health insurers. This is the first publication of hard empirical evidence of risk selection in the Dutch health insurance market.     

Ecologic proxies for household income: how well do they work for the analysis of health and health care utilization?

BACKGROUND: Researchers often use census-derived measures of socioeconomic status (SES) when personal information is not available. Theory predicts that the resulting misclassification will blunt associations between outcomes and SES and that control for confounding by SES will be less effective. The purpose of this paper was to examine the magnitude of this problem using data from the National Population Health Survey (NPHS). METHODS: Subjects were 4,037 respondents to the NPHS who were linked to the Ontario Health Insurance Plan. An ecologic measure of income was obtained by linkage of subjects' postal codes to the Census. RESULTS: The relationships between the ecologic-level measure and health outcomes or health services utilization were attenuated in comparison to the relationships relative to the direct measure of household income. The ecologic measure also produced poorer control for confounding by income in the analysis of other health relationships. CONCLUSIONS: Many interesting public health and health services questions can be addressed only with the use of ecologic level socioeconomic information. While most of the results were qualitatively similar when the direct and ecologic measures were compared, researchers and users of research findings should be aware that attenuated or potentially misleading findings may result from the use of these methods.     

Use of health care services by ethnic minorities in The Netherlands: do patterns differ?

BACKGROUND: This article examines the nature of ethnic differences in health care utilisation by assessing patterns of use in addition to single service utilisation. METHODS: Data were derived from the Second Dutch National Survey of General Practice. A nationally representative sample of 104 general practices participated in this survey. Data on health and health service utilisation were collected through face-to-face interviews. Based on a random sample per practice, a total of 12 699 Dutch-speaking people were interviewed, regardless of ethnic background. An additional study among a random sample of 1339 people from the four largest minority groups in The Netherlands was conducted. These four groups comprised people from Turkey, Surinam, Morocco, and The Netherlands Antilles. Multilevel analyses were performed to investigate ethnic differences in health care utilisation, adjusting for socio-economic status, health status, and level of urbanisation. RESULTS: Differences in utilisation patterns were particularly marked for people with a Moroccan, Turkish, or Antillean background. Compared to the other groups, Surinamese were more likely to have had contact with any professional health care service. No evidence was found that the gate keeping role of general practitioners in The Netherlands functions less effectively among the ethnic minority groups as compared to the indigenous population. CONCLUSION: The analysis of patterns of utilisation proved to supply useful information concerning the relationship between ethnicity and use of health care services in addition to figures concerning single service use only.     

Potential determinants of deductible uptake in health insurance: How to increase uptake in The Netherlands?

In health insurance, voluntary deductibles are offered to the insured in return for a premium rebate. Previous research has shown that 11 % of the Dutch insured opted for a voluntary deductible (VD) in health insurance in 2014, while the highest VD level was financially profitable for almost 50 % of the population in retrospect. To explain this discrepancy, this paper identifies and discusses six potential determinants of the decision to opt for a VD from the behavioral economic literature: loss aversion, risk attitude, ambiguity aversion, debt aversion, omission bias, and liquidity constraints. Based on these determinants, five potential strategies are proposed to increase the number of insured opting for a VD. Presenting the VD as the default option and providing transparent information regarding the VD are the two most promising strategies. If, as a result of these strategies, more insured would opt for a VD, moral hazard would be reduced.     

Addressing the health disadvantage of rural populations: How does epidemiological evidence inform rural health policies and research?

We reviewed evidence of any apparently significant 'rural-urban' health status differentials in developed countries, to determine whether such differentials are generic or nation-specific, and to explore the nature and policy implications of determinants underpinning rural-urban health variations. A comprehensive literature review of rural-urban health status differentials within Australia, New Zealand, Canada, the USA, the UK, and a variety of other western European nations was undertaken to understand the differences in life expectancy and cause-specific morbidity and mortality. While rural location plays a major role in determining the nature and level of access to and provision of health services, it does not always translate into health disadvantage. When controlling for major risk determinants, rurality per se does not necessarily lead to rural-urban disparities, but may exacerbate the effects of socio-economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions. Programs to improve rural health will be most effective when based on policies which target all risk determinants collectively contributing to poor rural health outcomes. Focusing solely on 'area-based' explanations and responses to rural health problems may divert attention from more fundamental social and structural processes operating in the broader context to the detriment of rural health policy formulation and remedial effort.     

Who transitions from private to public health insurance?: Lessons from expansions of the State Children's Health Insurance Program

This paper examines families of children who transition from private to public health insurance. These transitions include, but are not limited to, transitions that constitute crowd-out. We pool longitudinal panels from the Survey of Income and Program Participation (SIPP) covering 1990 to 2005. The annual rate of children who transition from private to public coverage more than doubled over this period, although it remains small. Transitioning children in recent years are typically in working families with median incomes of around 200% of poverty. Children who transition from private to public coverage are more likely to belong to minority groups, to have lower incomes, and to be in poorer health than children remaining privately insured. Public coverage now provides important protections for low-income working families, especially those with children in poor health. These findings underscore the need to implement post-health-reform policies with an eye towards possible adverse selection into public programs.     

How do economic downturns affect the mental health of children? Evidence from the National Health Interview Survey

Research linking economic conditions and health often does not consider children's mental health problems, which are the most common and consequential health issues for children and adolescents. We examine the effects of unemployment rates and housing prices on well‐validated child and adolescent mental health outcomes and use of special education services for emotional problems in the 2001–2013 National Health Interview Survey. We find that the effects of economic conditions on children's mental health are clinically and economically meaningful; children's mental health outcomes worsen as the economy weakens. The effects of economic conditions on child and adolescent mental health are pervasive, found in almost every subgroup that we examine. The use of special education services for emotional problems also rises when economic conditions worsen. Our analyses of possible mechanisms that link economic conditions to child mental health suggest that parental unemployment cannot fully explain the relationship between economic conditions and child mental health.     

The developmental origins of health and disease: where do we go from here?

A large number of studies have shown associations between birth weight and later adult disease, and these studies have ignited an interest in the developmental origins of disease and health. A paper in this volume of Epidemiology finds an overall U-shaped association between birth weight and all-cause mortality in a large Danish cohort. In this commentary, I discuss some of the issues that are important to epidemiologic studies concerned with the developmental origins of disease and health. These include considerations of causality and the public health/clinical relevance of the developmental origins of disease. I suggest that this area of research needs to move away from simply describing the association of birth weight with disease/health outcomes. Instead, we must aim to understand whether there are modifiable risk factors during the developmental period that are importantly causally related to later disease outcomes in ways that mean public health interventions should be aimed at the developmental period.     

Assessing determinants of health care prepayment in China: Economic growth or government willingness? New evidence from the continuous wavelet analysis

Significant prepayment of health care is a crucial factor to ensure that all individuals have access to effective health services at affordable prices. The research questions we address here are as follows: What role does economic growth play in changing the level of health care prepayment? Does government's willingness to spend more on health mean higher prepayment rates in the health financing system? What are their dynamic relationships? These questions are addressed in China over the 1978 to 2014 period by employing the continuous wavelet analysis. We focus in particular on their correlations and lead‐lag relationships across different frequency bands. Our findings clearly show that overall government willingness has a positive effect on health care prepayment level, while the impact of economic growth varies in the time‐frequency domain. This variation could be demonstrated in 1980 to 1998, when the positive correlation between economic growth and health care prepayment level in the short term turned negative in the medium and long term, which indicated that China could not achieve mutual development of economic growth and social welfare within the market‐oriented health system. Notably, the time‐varying analysis indicates that China's new round of medical system reform since 2006 plays an important role in changing the correlations and lead‐lag relationships. In particular, health care prepayment tended to lead government willingness during the 2006 to 2012 period since the increase of health subsidies and expenditures strengthened government responsibility over the health sector, and there existed a persistent mutual stimulation between economic growth and health care prepayment level across all frequency bands along with the reform.     

The burden of disease from air pollution in Israel: How do we use burden estimates to advance public health?

In an article recently published in the IJHPR, Ginsberg and colleagues from Israel’s Public Health Services estimate the disease burden from airborne particulate matter in Israel. Using national data on the concentration of PM_2.5 (particulate matter less than 2.5 μm in aerodynamic diameter) and risk estimates from meta-analyses, they calculate that about 2000 deaths (4.7% of total deaths) are attributable to air pollution. Although inherently subject to uncertainty, such estimates are useful for motivating public health protection and gauging the stringency of any needed regulations. However, Israel does not yet have an evidence-based process for air quality regulation comparable to that of the United States, which has evolved over the 45 years since passage of the Clean Air Act. In fact, Israel has only recently promulgated a national standard for airborne particulate matter and quantitative risk assessment has not been an element of regulatory decision-making. The report by Ginsberg and colleagues represents a useful beginning and should initiate discussion of the role of burden estimation and risk assessment more broadly in regulations intended to advance environmental health in Israel.     

A systematic review and meta-analysis of racial disparities in prenatal care in California: How much? Does insurance matter?

This meta-analysis compares California to 13 states with regard to adequacy of prenatal care in the context of the major Medicaid expansion. It shows a reduction in prenatal care inadequacy after 1992, especially in California. It also shows persistent racial ethnic disparities. By examining how California differed from other states, this study provides not only benchmarks for attaining the Healthy People 2010 goal of 90% adequacy but also possible strategies for achieving this goal. Attaining the Healthy People 2010 objective for prenatal care for California as a whole will require further efforts to understand and address racial/ethnic and insurance-related inequalities.     

Social dimensions of mortality from external causes in Lithuania: do education and place of residence matter?

Summary. Objectives To assess inequalities in mortality from external causes by the level of education and the place of residence during the period of socio-economic transition in Lithuania. Methods Information on deaths, place of residence, and the level of education of persons aged 25 and older was derived from the National Database of Lithuania and censuses for 1989 (n = 3537) and 2001 (n = 4790). Results Mortality from external causes of Lithuanian urban and rural populations was strongly associated with the level of education. Educational inequalities increased throughout the period of socio-economic transition. In urban areas, mortality among the least educated population was 3.20 times higher in 1989 and 3.37 times higher in 2001, compared to those with university-level education. In rural areas the educational mortality rate ratios reached 3.47 and 4.33, respectively. The greatest educational inequalities were observed in suicide mortality, especially among males. Conclusions The results of this study disclosed increasing inequalities in mortality from external causes. Less educated populations, especially in rural areas, should receive particular attention in the development of strategies for the prevention of mortality from external causes. Submitted: 29 June 2004; Accepted: 8 March 2006