Peer Reviewed: Awareness, Treatment, and Control of Hypertension and Hypercholesterolemia Among Insured Residents of New York City, 2004

Introduction

Health care access and sociodemographic characteristics may influence chronic disease management even among adults who have health insurance. The objective of this study was to examine awareness, treatment, and control of hypertension and hypercholesterolemia, by health care access and sociodemographic characteristics, among insured adults in New York City.

Methods

Using data from the 2004 New York City Health and Nutrition Examination Survey, we investigated inequalities in the diagnosis and management of hypertension and hypercholesterolemia among insured adults aged 20 to 64 years (n = 1,334). We assessed differences in insurance type (public, private) and routine place of care (yes, no), by sociodemographic characteristics.

Results

One in 10 participants with hypertension and 3 in 10 with hypercholesterolemia were unaware and untreated. Having a routine place of care was associated with treatment and control of hypertension and with awareness, treatment, and control of hypercholesterolemia, after adjusting for insurance type, age, sex, race/ethnicity, foreign birth, income, and education. Differences in systolic blood pressure and total cholesterol between people with versus without a routine place of care were 2 to 3 times the difference found between people with public versus private insurance. Few differences were associated with sociodemographic characteristics after adjusting for routine place of care and insurance type; however, male sex, younger age, Asian race, and foreign birth with short-term US residence reduced the odds of having a routine place of care. Neither income nor education predicted having a routine place of care.

Conclusion

Sociodemographic characteristics may influence chronic disease management among the insured through health care access factors such as having a routine place of care.     

Peer Reviewed: The Latino Health Insurance Program: A Pilot Intervention for Enrolling Latino Families in Health Insurance Programs,East Boston,Massachusetts, 2006-2007

Background

Thirteen percent of Latinos in Massachusetts lack health insurance, the highest rate of any ethnic or racial group. Families without health insurance are more likely to be in poor or fair health, to lack a regular medical provider, and to not have visited a medical provider in the past year.

Context

The Latino Health Insurance Program is designed as a response both to the high rate of uninsurance among Latinos in Boston and to the multiple obstacles that keep Latino parents from applying for insurance for their families.

Methods

In 2006, we designed and implemented a culturally competent model of health insurance outreach, education, enrollment and maintenance, and referral for primary care and social services for Latino families.

Consequences

Year 1 results of the Latino Health Insurance Program are promising. Six community members were hired and trained as case managers. A total of 230 children and adults were enrolled or re-enrolled in health insurance programs and received other needed services. Retention was near 100% after 1 year.

Interpretation

The Latino Health Insurance Program may serve as a model health insurance access program that can be adapted by community-based organizations and also can be incorporated into public agency programs for Latinos and other immigrant and minority groups. The program continues to serve East Boston residents and was expanded in 2008.     

COBRA ARRA Subsidies: Was the Carrot Enticing Enough?

Objective

To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008–2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions.

Study Design/Data Collection

Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate).

Principal Findings

Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending.

Conclusion

Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.     

The impact of health insurance in Africa and Asia: a systematic review

Objective

To evaluate the impact of health insurance on resource mobilization, financial protection, service utilization, quality of care, social inclusion and community empowerment in low- and lower-middle-income countries in Africa and Asia.

Methods

A systematic search for randomized controlled trials, quasi-experimental and observational studies published before the end of 2011 was conducted in 20 literature databases, reference lists of relevant studies, web sites and the grey literature. Study quality was assessed with a quality grading protocol.

Findings

Inclusion criteria were met by 159 studies – 68 in Africa and 91 in Asia. Most African studies reported on community-based health insurance (CBHI) and were of relatively high quality; social health insurance (SHI) studies were mostly Asian and of medium quality. Only one Asian study dealt with private health insurance (PHI). Most studies were observational; four had randomized controls and 20 had a quasi-experimental design. Financial protection, utilization and social inclusion were far more common subjects than resource mobilization, quality of care or community empowerment. Strong evidence shows that CBHI and SHI improve service utilization and protect members financially by reducing their out-of-pocket expenditure, and that CBHI improves resource mobilization too. Weak evidence points to a positive effect of both SHI and CBHI on quality of care and social inclusion. The effect of SHI and CBHI on community empowerment is inconclusive. Findings for PHI are inconclusive in all domains because of insufficient studies.

Conclusion

Health insurance offers some protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.     

Is Ghana’s pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana

Background

Protecting the poor and vulnerable against the cost of unforeseen ill health has become a global concern culminating in the 2005 World Health Assembly resolution urging member states to ensure financial protection to all citizens, especially children and women of reproductive age. Ghana provides financial protection to its citizens through the National Health Insurance Scheme (NHIS). Launched in 2004, its proponents claim that the NHIS is a pro-poor financial commitment that implements the World Health Assembly resolution.

Methods

Using 2011 survey data collected in seven districts in northern Ghana from 5469 women aged 15 to 49 the paper explores the extent to which poor child-bearing age mothers are covered by the NHIS in Ghana’s poorest and most remote region. Factors associated with enrolment into the NHIS are estimated with logistic regression models employing covariates for household relative socio-economic status (SES), location of residence and maternal educational attainment, marital status, age, religion and financial autonomy.

Results

Results from the analysis showed that 33.9 percent of women in the lowest SES quintile compared to 58.3 percent for those in the highest quintile were insured. About 60 percent of respondents were registered. However, only 40 percent had valid insurance cards indicating that over 20 percent of the registered respondents did not have insurance cards. Thus, a fifth of the respondents were women who were registered but unprotected from the burden of health care payments. Results show that the relatively well educated, prosperous, married and Christian respondents were more likely to be insured than other women. Conversely, women living in remote households that were relatively poor or where traditional religion was practised had lower odds of insurance coverage.

Conclusion

The results suggest that the NHIS is yet to achieve its goal of addressing the need of the poor for insurance against health related financial risks. To ultimately attain adequate equitable financial protection for its citizens, achieve universal health coverage in health care financing, and fully implement the World Health Assembly resolution, Ghana must reform enrolment policies in ways that guarantee pre-payment for the most poor and vulnerable households.

     

Diabetes treatment and control: the effect of public health insurance for the poor in Mexico

Objective

To analyse the effect of enrolment in the public health insurance scheme known as Seguro Popular [People’s Insurance] on access to health resources, treatment and blood glucose control among poor adults with diabetes in Mexico.

Methods

We analysed cross-sectional data from the 2006 National Health and Nutrition Survey and compared health care access and biological health outcomes, specifically glycosylated haemoglobin (HbA1c) levels, among adults with diabetes who were enrolled in the Seguro Popular (treatment group) and those who had no health insurance (control group). Standard propensity score matching was used to create a highly comparable control group.

Findings

Adults with diabetes who were enrolled in the Seguro Popular had significantly more access than comparable uninsured adults to some type of blood glucose control test (by a difference of 9.5 percentage points; 95% confidence interval, CI: 2.4–16.6) and to insulin injections (3.13 more per week; 95% CI: 0.04–6.22). Those with insurance were also significantly more likely to have appropriately-controlled blood glucose levels (HbA1c ≤ 7%) than their uninsured counterparts (by a difference of 5.6 percentage points; 95% CI: 0.9–10.3). Very poor glucose control (HbA1c > 12%) was found in a significantly smaller proportion of adults in the insured group than in the uninsured group (by a difference of 17.5 percentage points; 95% CI: 6.5–28.5).

Conclusion

The Seguro Popular appears to have improved access to health care and blood glucose control among poor adults with diabetes in Mexico, and it may have had a positive effect on the management of other chronic health conditions, but its long-term effects are yet to be demonstrated. Although the findings are most relevant to Mexico, they may also be applicable to other developing countries seeking to improve health-care coverage for the poor by expanding their public health insurance programmes.     

Delay in seeing a doctor due to cost: disparity between older adults with and without disabilities in the United States

Objective

To examine the disparity in delaying seeing a doctor due to cost between older adults with and without disabilities, and whether the disparity could be explained by health and financial variables.

Data Sources

Nationally representative sample of community-dwelling adults aged ≥65 who have health insurance and a usual source of care from the 2006 Behavioral Risk Factor Surveillance System (n = 85,015).

Study Design

This cross-sectional study used sequential logistic regression models to examine the associations of delaying seeing a doctor due to cost with disability status, including demographic, health, and financial variables.

Principal Findings

Older adults with disabilities had significantly higher odds of delaying seeing a doctor due to cost compared to older adults without disabilities after controlling for demographic, health, and financial factors. Although health and financial variables collectively attenuated the disparity, they did not fully explain the disparity.

Conclusions

Despite having health insurance and a usual source of care, older adults with disabilities encountered greater economic difficulties in seeing a doctor than their counterparts without disabilities. Policy makers should continue addressing the economic burden to improve timely visits to health care providers.     

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program

Objective

To estimate the relationship between physicians'' acceptance of new Medicaid patients and access to health care.

Data Sources

The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.

Study Design

Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children''s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.

Principal Findings

Nearly 16 percent of children with a significant health condition or development delay had a doctor''s office or clinic indicate that the child''s health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar.

Conclusions

Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients.     

Progress and challenges of the rural cooperative medical scheme in China

Problem

During China’s transition to a market economy in the 1980s and 1990s, the rural population faced substantial barriers to accessing health care and encountered heavier financial burdens than urban residents in paying for necessary health services.

Approach

In 2003, China started to implement a rural cooperative medical scheme (RCMS), mainly through government subsidies. The scheme operates at the county level and offers a modest benefit package.

Local setting

In spite of rapid economic growth since the early 1980s, income disparities in China have increased, particularly between rural and urban populations. In response, the government has put greater emphasis on social development, including health system development. Examples are the prioritization of improved access to health services and the reduction of the burden of payment for necessary services.

Relevant changes

After 10 years of implementation, the RCMS now provides coverage to the entire rural population and has substantially improved access to health care. Yet despite a drop in out-of-pocket payments as a proportion of total health expenditure, paying for necessary services continues to cause financial hardship for many rural residents.

Lessons learnt

In its first decade, the RCMS made progress through political mobilization, government subsidies, the readiness of the health-care delivery system, and the availability of a monitoring and evaluation system. Further improving the RCMS will require a focus on cost containment, quality improvement and making the scheme portable.     

Effects of Health Guidance on Outpatient and Pharmacy Expenditures: A Disease- and Drug-Specific 3-Year Observational Study Using Propensity-Score Matching

Background

Evidence is lacking on whether health guidance for metabolic syndrome reduces health care expenditures. The author used propensity-score matching to evaluate the effects of health guidance on health care expenditure.

Methods

Men who did and did not receive health guidance from a health insurance society (approximately 60 000 covered lives) were matched (n = 397 respectively) using propensity scores. Health insurance claims were compared using cumulative health care expenditures for metabolic syndrome-related outpatient medical care and drug costs for the period from the initial consultation to 3 years later.

Results

No difference was observed between intervention and control groups in cumulative outpatient charges or drug costs related to metabolic syndrome. However, regression analysis using the Tobit model showed that health guidance resulted in a small, nonsignificant reduction in health care expenditure.

Conclusions

Health guidance for metabolic syndrome did not reduce outpatient charges or drug costs related to metabolic syndrome during the 3-year period after the intervention. Findings from Tobit regression suggest that health guidance might eventually result in savings, but this hypothesis remains untested.Key words: health guidance, health insurance claims, propensity-score matching, PDM (proportional distribution method), metabolic syndrome     

Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania

Objective

To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania.

Methods

Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi’s model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care.

Findings

Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts.

Conclusion

The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.     

Has Income-related Inequity in Health Care Utilization and Expenditures Been Improved? Evidence From the Korean National Health and Nutrition Examination Survey of 2005 and 2010

Objectives

The purpose of this study is to examine and explain the extent of income-related inequity in health care utilization and expenditures to compare the extent in 2005 and 2010 in Korea.

Methods

We employed the concentration indices and the horizontal inequity index proposed by Wagstaff and van Doorslaer based on one- and two-part models. This study was conducted using data from the 2005 and 2010 Korean National Health and Nutrition Examination Survey. We examined health care utilization and expenditures for different types of health care providers, including health centers, physician clinics, hospitals, general hospitals, dental care, and licensed traditional medical practitioners.

Results

The results show the equitable distribution of overall health care utilization with pro-poor tendencies and modest pro-rich inequity in the amount of medical expenditures in 2010. For the decomposition analysis, non-need variables such as income, education, private insurance, and occupational status have contributed considerably to pro-rich inequality in health care over the period between 2005 and 2010.

Conclusions

We found that health care utilization in Korea in 2010 was fairly equitable, but the poor still have some barriers to accessing primary care and continuing to receive medical care.     

Barriers to access and the purchasing function of health equity funds: lessons from Cambodia

Problem

High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined.

Approach

Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers.

Local setting

Two-thirds of total health expenditure consists of patients’ out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes.

Relevant changes

HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care.

Lessons learned

HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.     

Do Interventions to Prevent Lifestyle-Related Diseases Reduce Healthcare Expenditures? A Randomized Controlled Clinical Trial

Background

In 2008, the Japanese government implemented a program of health lifestyle interventions to reduce health care expenditure. This study evaluated whether these interventions decreased health care expenditures.

Methods

The study enrolled 99 participants insured by Japanese National Health Insurance, who, in our previous study conducted in 2004, were allocated by random sampling into an intervention group (50 participants) and a control group (49 participants). In the intervention group, we used a health support method that facilitated the attainment of goals established by each participant. The control group received instruction in exercise, as well as health support using publically available media. Although 3 participants in the intervention group and 9 participants in the control group did not participate in a follow-up health examination 1 year after the intervention, the health care expenditures of all initial participants were assessed. Expenditures before and after the intervention were compared within and between groups. Data on health care expenditures were obtained from inpatient, outpatient, pharmacy, and dental health insurance claims.

Results

After the intervention, the pharmacy and dental expenditures were significantly higher in the intervention group, while the pharmacy expenditure was significantly higher in the control group. However, there was no significant difference in any medical expenditure item between the intervention and control groups before or after the intervention.

Conclusions

No significant differences were observed in short-term medical expenses for any medical expenditure item after a lifestyle intervention.Key words: health policy, randomized controlled trial, prevention, lifestyle-related diseases, health care expenditures     

Peer Reviewed: Assessing Perceptions of and Responses to Multiple Health Risks Among the Southern Poor

Introduction

We explored perceptions of and responses to multiple health risks among people living in poverty in the southern United States.

Methods

We conducted 12 focus groups and interviewed 66 focus group participants in 3 southern US cities (Birmingham, Alabama; Jackson, Mississippi; and Columbia, South Carolina). Thematic analysis was used to identify major themes.

Results

Study participants worried most about chronic health conditions and the costs to treat those conditions. Feelings of threat were influenced by family health history and race. Barriers to health-protective behaviors included time, work, family, apathy, and low response efficacy. Physical activity and checking blood pressure were the health-protective behaviors in which participants most often engaged.

Conclusion

Our results will be useful for the development of interventions that target the southern poor. Intervention messages should address the barriers that poor people face when attempting to engage in health-protective behaviors and should help strengthen people''s confidence in their ability to change their behaviors.     

Health risks and informal employment in South Africa: does formality protect health?

Background:

The association between work and health has not been well explored in the context of economically developing countries, largely due to inadequate data.

Objectives:

The objective of this study was to identify the association between informal wage work and health in South Africa using a newly available data set that includes detailed information on both employment and health.

Methods:

To explore the relationship between formality, work, and health in South Africa, data from the first (2008) wave of the National Income Dynamic Study (NIDS) were analyzed. We constructed a “formality index” which represents work arrangements on a continuum of formality to informality allowing for a more nuanced analysis of the association between wage work and health.

Results:

We found that formality of employment was significantly associated with health in South Africa, but that the protective effect of formality in employment on health was largely derived from the higher levels of income earned through more formal types of employment. Nevertheless, we did find that the association between informality and poor health was significantly greater for women in wage employment than for males.     

Willingness to Join and Pay for the Newly Proposed Social Health Insurance among Teachers in Wolaita Sodo Town,South Ethiopia

Background

Cost-sharing between beneficiaries and governments is critical to achieve universal health care coverage. To address this, Ethiopia is currently introducing Social Health Insurance. However, there has been limited evidence on willingness to join the newly proposed insurance scheme in the country. The purpose of this study is to assess willingness to join and pay for the scheme among teachers in Wolaita Sodo Town government educational institutions, South Ethiopia.

Methods

A cross-sectional study was conducted from February 5 to March 10, 2012 on 335 teachers. Stratified simple random sampling technique was used and data were collected using structured interviewer administered questionnaire. Binary and multiple logistic regressions were used to estimate the crude and adjusted odds ratios for willingness to pay.

Results

Three hundred twenty-eight teachers participated in the study with response rate of 98%. About 55% of the teachers had never heard of any type of health insurance scheme. However, 74.4% of them were willing to pay for the suggested insurance scheme. About 47% of those who were willing to pay agreed to contribute greater than or equal to 4% of their monthly salaries. Willingness to pay was more likely among those who had heard about health insurance, had previous history of inability to pay for medical bills and achieved higher educational status.

Conclusion

The majority of the teachers were willing to join social health insurance; however, adequate awareness creation and discussion should be made with all employees at various levels for the successful implementation of the scheme.     

The Role of Stigma in Access to Health Care for the Poor

Context

The Affordable Care Act provides new Medicaid coverage to an estimated 12 million low-income adults. Barriers to access or quality could hamper the program''s success. One of these barriers might be the stigma associated with Medicaid or poverty.

Methods

Our mixed-methods study involved 574 low-income adults and included data from an in-person survey and follow-up interviews. Our analysis of the interviews showed that many participants who were on Medicaid or uninsured described a perception or fear of being treated poorly in the health care setting. We defined this experience as stigma and merged our qualitative interviews coded for stigma with our quantitative survey data to see whether stigma was related to other sociodemographic characteristics. We also examined whether stigma was associated with access to care, quality of care, and self-reported health.

Findings

We were unable to identify other sociodemographic characteristics associated with stigma in this low-income sample. The qualitative interviews suggested that stigma was most often the result of a provider-patient interaction that felt demeaning, rather than an internalized sense of shame related to receiving public insurance or charity care. An experience of stigma was associated with unmet health needs, poorer perceptions of quality of care, and worse health across several self-reported measures.

Conclusions

Because a stigmatizing experience in the health system might interfere with the delivery of high-quality care to new Medicaid enrollees, further research and policy interventions that target stigma are warranted.