Trends in Health Care Financial Burdens, 2001 to 2009

Context: Over the past decade, health care spending increased faster than GDP and income, and decreasing affordability is cited as contributing to personal bankruptcies and as a reason that some of the nonelderly population is uninsured. We examined the trends in health care affordability over the past decade, measuring the financial burdens associated with health insurance premiums and out-of-pocket costs and highlighting implications of the Affordable Care Act for the future financial burdens of particular populations.Methods: We used cross sections of the Medical Expenditure Panel Survey Household Component (MEPS-HC) from 2001 to 2009. We defined financial burden at the health insurance unit (HIU) level and calculated it as the ratio of expenditures on health care—employer-sponsored insurance coverage (ESI) and private nongroup premiums and out-of-pocket payments—to modified adjusted gross income.Findings: The median health care financial burden grew on average by 2.7% annually and by 21.9% over the period. Using a range of definitions, the fraction of households facing high financial burdens increased significantly. For example, the share of HIUs with health care expenses exceeding 10% of income increased from 35.9% to 44.8%, a 24.8% relative increase. The share of the population in HIUs with health care financial burdens between 2% and 10% fell, and the share with burdens between 10% and 44% rose.Conclusions: We found a clear trend over the past decade toward an increasing share of household income devoted to health care. The ACA will affect health care spending for subgroups of the population differently. Several groups’ burdens will likely decrease, including those becoming eligible for Medicaid or subsidized private insurance and those with expensive medical conditions. Those newly obtaining coverage might increase their health spending relative to income, but they will gain access to care and the ability to spread their expenditures over time, both of which have demonstrable economic value.     

少数民族居民对疟防费用和集资意愿调查

目的　探讨爱尼人和基诺族对疟疾防治费用的支付能力和意愿及其研究方法。方法　对户主进行问卷调查 ,对资料进行统计学处理。结果　向东村爱尼人的人均年收入和现金收入较石嘴村基若族的高 ,但年人均医药费支出更低 ,支付能力更强 ;向东和石嘴愿意集资开展疟疾防治的家庭比例分别是 96 4 % (95 %CI:87 5 %～ 99 6 % )和84 1% (95 %CI :6 9 9%～ 93 4 % ) ,人均年愿意集资额分别为 (13 2 8± 2 2 1)元和 (4 35± 1 71)元 ;高、中、低收入家庭的人均年愿意集资额无显著性差异 (P >0 0 5 )。结论　人们的集资意愿除受支付能力外 ,尚受其它因素的影响。     

Sri Lanka and the possibilities of achieving universal health coverage in a poor country

Sri Lanka has been lauded for providing good health coverage at a low cost despite having a modest per capita income. This article identifies the unique historical factors that enabled Sri Lanka to achieve near universal coverage, but it also discusses how this achievement is now being undermined by inadequate government investment in health services, the burdens of non-communicable diseases, and the growing privatisation of health services. In doing so, the article highlights the challenges of achieving and maintaining universal health coverage in a relatively low income country with a health system designed to treat infectious diseases and provide child and maternal health services as the country undergoes an epidemiological transition from infectious to non-communicable diseases. Using updated information on developments in the Sri Lankan health system, this article argues, in contrast with earlier publications, that Sri Lanka is no longer providing good health at a low cost. It shows that Sri Lanka’s low investment in health is detrimental and not an asset to achieving good health. The article also questions the possibilities of providing coverage for noncommunicable diseases at a low cost. The article has four main sections. The first details Sri Lanka’s accomplishments in moving toward universal health coverage. The second identifies the factors enabling Sri Lanka to do so. The third describes the equity and access challenges the health system now confronts. The fourth assesses what the Sri Lankan experience suggests about the requirements for universal health coverage when providing health services for treating non-communicable diseases becomes an important consideration.     

Affordability of Heathy,Equitable and More Sustainable Diets in Low-Income Households in Brisbane before and during the COVID-19 Pandemic

The COVID-19 pandemic has increased food insecurity worldwide, yet there has been limited assessment of shifts in the cost and affordability of healthy, equitable and sustainable diets. This study explores the impact of the COVID-19 pandemic and income supplements provided by the Australian government on diet cost and affordability for low-income households in an Australian urban area. The Healthy Diets ASAP method protocol was applied to assess the cost and cost differential of current and recommended diets before (in 2019) and during the COVID-19 pandemic (late 2020) for households with a minimum-wage and welfare-only disposable household income, by area of socioeconomic disadvantage, in Greater Brisbane, Queensland, Australia. Data were collected between August and October, 2020, from 78 food outlets and compared with data collected in the same locations between May and October, 2019, in an earlier study. The price of most healthy food groups increased significantly during the pandemic—with the exception of vegetables and legumes, which decreased. Conversely, the price of discretionary foods and drinks did not increase during the pandemic. The cost of the current and recommended diets significantly increased throughout this period, but the latter continued to be less expensive than the former. Due to income supplements provided between May and September 2020, the affordability of the recommended diet improved greatly, by 27% and 42%, for households with minimum-wage and welfare-only disposable household income, respectively. This improvement in the affordability of the recommended diet highlights the need to permanently increase welfare support for low-income families to ensure food security.     

Comment--defining health insurance affordability: unobserved heterogeneity matters

Affordability is a vague concept. Bundorf and Pauly [Bundorf, M.K., Pauly, M.V., 2006. Is health insurance affordable for the uninsured? Journal of Health Economics 25 (4), 650-673] address this problem by establishing clear working definitions of affordability, and they use these definitions to estimate the percent of the uninsured who can afford insurance. When they establish their definitions of affordability, they use a microeconomic model that omits essential characteristics of the health insurance market. This comment suggests alternative definitions that better incorporate the structure of the health insurance market, discusses both endogeneity and specification problems that might occur when implementing their econometric model to estimate the fraction of "uninsured afforders," and then recommends ways to reduce omitted variable bias and endogeneity bias.     

The cost of a healthy and sustainable diet – who can afford it?

Objective: Climate change is affecting the ability of food systems to provide sufficient nutritious and affordable foods at all times. Healthy and sustainable (H&S) food choices are important contributions to health and climate change policy efforts. This paper presents empirical data on the affordability of a food basket that incorporates principles of health and sustainability across different food sub‐systems, socioeconomic neighbourhoods and household income levels in Greater Western Sydney, Australia. Methods: A basket survey was used to investigate the cost of both a typical basket of food and a hypothetical H&S basket. The price of foods in the two baskets was recorded in five neighbourhoods, and the affordability of the baskets was determined across household income quintiles. Results: The cost of the H&S basket was more than the typical basket in all five socioeconomic neighbourhoods, with most disadvantaged neighbourhood spending proportionately more (30%) to buy the H&S basket. Within household income levels, the greatest inequity was found in the middle income neighbourhood, showing that households in the lowest income quintile would have to spend up to 48% of their weekly income to buy the H&S basket, while households in the highest income quintile would have to spend significantly less of their weekly income (9%). Conclusion: The most disadvantaged groups in the region, both at the neighbourhood and household level, experience the greatest inequality in affordability of the H&S diet. Implications: The results highlight the current inequity in food choice in the region and the underlying social issues of cost and affordability of H&S foods.     

Cigarette price, affordability and smoking prevalence in the European Union

Aims To describe current and recent changes in cigarette affordability across the current 27 European Union (EU) Member States, and to assess the impact of these changes on smoking prevalence in countries that were EU members in 2004 (old Member States) compared to countries that have joined since 2004 (new Member States). Design Investigation of cigarette affordability using the minutes of labour measure, and comparisons of changes in affordability, tax and smoking prevalence in old and new EU Member States. Participants Current 27 EU Member States. Settings European Union. Measurements Cigarette prices, overall tax yield and incidence, hourly wages and smoking prevalence in the EU were obtained from published sources, and the affordability of the EU Most Popular Price Category (MPPC) cigarettes estimated as the number of minutes of labour required to earn the price of 20 cigarettes in the years 2003, 2006 and 2009. Findings The mean [standard deviation (SD)] number of minutes of labour required to purchase 20 MPPC cigarettes in EU Member States in 2009 was 31.3 (SD 10.7), but ranged fourfold across the EU, and was significantly higher in new than old Member States. The number of minutes of labour measure increased more, although not significantly so, between 2003 and 2009 in new [mean (SD) 12.1 (10.9)] than in old [6.7 (4.0)] Member States, largely because of proportionately higher increases in taxation. However, there was no correlation between change in affordability and change in smoking prevalence in recent years. Conclusions Cigarette affordability varies substantially and cigarettes are generally becoming less affordable in European Union Member States. However, these reductions in affordability do not appear to have impacted substantially on smoking prevalence in recent years.     

Analysis of the injection force of solostar® compared with other disposable insulin pen devices at constant volume flow rates

Insulin pen devices have greatly enhanced the portability and accessibility to insulin therapy for millions of people with diabetes. Comparison research data should be reviewed thoroughly.In this issue of Journal of Diabetes Science and Technology, the study presented by Thomas van der Burg is balanced in number of samples tested, same tensile meter, and identical units per second delivery rate into an open beaker. Mean plateau force of SoloSTAR^® and KwikPen™ were significantly lower. KwikPen and SoloSTAR utilized 5-mm length 31-gauge (G) needles vs 6-mm 31G needles for FlexPen^® and Next Generation FlexPen^®, perhaps skewing results in favor of shorter needles instead of device design.Individual understanding of correct insulin use, appropriate self-monitoring of blood glucose, vision and dexterity capability, and affordability of therapy must be considered first. SoloSTAR holds one unique market advantage, delivery of up to 80 units of insulin per injection.     

Multidisciplinary DEprescribing review for Frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement

IntroductionDeprescribing is a strategy for reducing the use of potentially inappropriate medications for older adults. Limited evidence exists on the development of strategies to support healthcare professionals (HCPs) deprescribing for frail older adults in long-term care (LTC).ObjectiveTo design an implementation strategy, informed by theory, behavioural science and consensus from HCPs, which facilitates deprescribing in LTC.MethodsThis study was consisted of 3 phases. First, factors influencing deprescribing in LTC were mapped to behaviour change techniques (BCTs) using the Behaviour Change Wheel and two published BCT taxonomies. Second, a Delphi survey of purposively sampled HCPs (general practitioners, pharmacists, nurses, geriatricians and psychiatrists) was conducted to select feasible BCTs to support deprescribing. The Delphi consisted of two rounds. Using Delphi results and literature on BCTs used in effective deprescribing interventions, BCTs which could form an implementation strategy were shortlisted by the research team based on acceptability, practicability and effectiveness. Finally, a roundtable discussion was held with a purposeful, convenience sample of LTC general practitioners, pharmacists and nurses to prioritise factors influencing deprescribing and tailor the proposed strategies for LTC.ResultsFactors influencing deprescribing in LTC were mapped to 34 BCTs. The Delphi survey was completed by 16 participants. Participants reached consensus that 26 BCTs were feasible. Following the research team assessment, 21 BCTs were included in the roundtable. The roundtable discussion identified lack of resources as the primary barrier to address. The agreed implementation strategy incorporated 11 BCTs and consisted of an education-enhanced 3-monthly multidisciplinary team deprescribing review, led by a nurse, conducted at the LTC site.ConclusionThe deprescribing strategy incorporates HCPs’ experiential understanding of the nuances of LTC and thus addresses systemic barriers to deprescribing in this context. The strategy designed addresses five determinants of behaviour to best support HCPs engaging with deprescribing.