Many older people need external support for their daily living. A large minority of older adults with low or modest pension incomes face financial strains from the high cost of illness, and many ...older people in urban areas live in social isolation. Indeed, population aging has become a policy topic of concern. The policy debate since the end of the twentieth century about the future of public pensions and health and long‐term care programs has increasingly framed the growing numbers of older people in alarmist terms. Unfounded claims about the unaffordability and unsustainability of social policies supporting older people have become common currency, often disguised as concerns about intergenerational justice. Such claims and concerns hinder clear thinking about proper social and fiscal policies, housing, health care, and labor markets to safeguard the well‐being of older people in aging societies.
•The COVID-19 pandemic provided a natural experiment of global ability to match supply of Intensive Care Unit (ICU) resources to unprecedented need.•In the United States (US), a fragmented healthcare ...infrastructure struggled to meet local demands despite the country having many more ICU beds per capita than most of Europe.•Economically vulnerable populations likely suffered adverse outcomes as a result.•The more centrally planned French healthcare system was able to transfer patients between regions in an attempt to match ICU bed capacity to demand.•These lessons are important to future national health emergencies because, without being able to match supply to demand, ICU care must be rationed and existing approaches to allocation of ICU resources do not have the ability to determine accurately who will receive benefit.
Successful deliberations over contentious issues require a publicly spirited citizenry that will encourage elected officials to promote what James Madison called the “permanent and aggregate ...interests” of the country. Unfortunately, atomizing forces have pulled American society apart, undermining trust and making collective action difficult. Residential segregation is one of those atomizing forces. Residential segregation undermines a commitment to civic virtue because it encourages people to think about fellow citizens as “others” with whom they have little in common. To address this situation, we must start by fixing our neighborhoods and creating local institutions that enhance trust and foster a public‐spirited democratic citizenry. For example, our existing educational policies reinforce the disparities associated with residential segregation and have created massive resource inequalities among school districts across the country. A useful first step would be to equalize school district funding to promote a more genuine equality of opportunity.
Engaging patients and the public with evidence is an ethical imperative because engagement is central to respect for persons and will likely improve health outcomes, facilitate the stewardship of ...resources, enhance prospects for justice, and build public trust. However, patient and public engagement is also morally complex, because evidence alone is never definitive. As patients and the public engage with evidence, value conflicts will arise and must be managed to achieve trustworthy decision making. We outline value conflicts likely to emerge in the following five settings: clinical care, health care organizations, public health, the regulatory context, and among payers. Using a variety of examples, we offer suggestions about how such conflicts may be managed, including providing more opportunities for democratic deliberation and having more explicit community discussion of how to balance personal choice and community well-being, transparent discussions of cost and quality outcomes, and greater patient engagement in community-based participatory research and the governance of learning health systems.
•Rates of avoidable hospitalizations in Manhattan fell between 2000 and 2017’.•Rates of avoidable hospitalizations in Manhattan are now lower than the rates in Paris.•There are large inequalities in ...avoidable hospitalizations within Manhattan and Paris.•Health reform in the U.S. did not reduce social inequalities in health care.•Social and economic inequalities within Paris have generated inequalities in health care.
France's system of universal health insurance (UHI) offers more equitable access to outpatient care than the patchwork system in the U.S., which does not have a UHI system. We investigate the degree to which the implementation of the Patient Protection and Affordable Care Act (ACA) has narrowed the gap in access to outpatient care between France and the U.S. To do so, we update a previous comparison of access to outpatient care in Manhattan and Paris as measured by age-adjusted rates of hospital discharge for avoidable hospital conditions (AHCs). We compare these rates immediately before and after the implementation of the ACA in 2014. We find that AHC rates in Manhattan declined by about 25% and are now lower than those in Paris. Despite evidence that access to outpatient care in Manhattan has improved, Manhattanites continue to experience greater residence-based neighborhood inequalities in AHC rates than Parisians. In Paris, there was a 3% increase in AHC rates and neighborhood-level inequalities increased significantly. Our analysis highlights the persistence of access barriers to outpatient care in Manhattan, particularly among racial and ethnic minorities, even following the expansion of health insurance coverage.
Those who emphasize the economic and social determinants of health argue that infant mortality is an important indicator of social well-being but has little to do with health services. The careful ...analysis of changes in infant mortality in the US, which includes both international and state-level comparisons by Peter Muennig, Megan M. Reynolds, Boshen Jiao, and Roman Pabayo lends support to the latter perspective while recognizing the complex array of factors that contribute to this outcome. Muennig, Reynolds, Jiao, and Pabayo argue that not only is material hardship a major factor contributing to infant mortality, but limited investment in the social safety net in the US compared with other wealthy nations exacerbates the risks among high-risk women in the US relative to other nations. Furthermore, they argue that the high cost of medical care faced by many American families erodes disposable income, contributing to psychological stress and material hardship, which contribute to infant mortality.
Japan has been aging faster than other industrialized nations, and its experience offers useful lessons to others. Japan has been willing to expand its welfare state with a long-term care (LTC) ...insurance to finance home care and nursing home care for frail elderly. As Ikegami shows, it created new facilities and expanded specialized staffing for home care, developed a country-wide assessment system and shifted responsibilities between the central and local authorities over that assessment and the determination of co-payments for LTC. Faced with rapid growth in demand for LTC, the government felt the need for new cost control measures. The Japanese experience illustrates that new social policies take time to develop. There is often a need to adjust. But there are also other lessons. The main one is that there is no direct relation between the degree of population aging and total health spending. While aging requires adjustments in the organization of care, and expanding LTC for frail elderly, international studies show there is no need to worry about the 'unaffordability' of aging. In this commentary, we have framed four "What, Why, Who, and How" questions about LTC to (re-)define the borderlines between public and private responsibilities for the range of activities for which some (but certainly not all) frail elderly as well as many non-elderly require support in daily life.
Trump and the Affordable Care Act Thompson, Frank J.; Gusmano, Michael K.; Shinohara, Shugo
Publius,
07/2018, Letnik:
48, Številka:
3
Journal Article
Recenzirano
Odprti dostop
This article assesses the politics and partial success of Congress in repealing the Affordable Care Act (ACA), known as Obamacare, with particular attention to lobbying by governors. Most Republican ...governors behaved as members of a vertical partisan coalition supporting the national party rather than defending insurance coverage in their states. But the activities of a significant minority of these governors impeded ACA retrenchment. We also examine the role of executive federalism, highlighting how state responses toTrump administrative initiatives affected ACA durability. The Trump administration drew on waivers, executive orders, funding decisions, administrative rules, the social media, and other executive branch tools to sabotage the health insurance exchanges and undercut Medicaid. As of 2018, the Trump administration actions had contributed to some erosion in exchange coverage, but far less than many had anticipated. The degree to which Medicaid waivers encouraged by the Trump administration will precipitate enrollment declines in that program remains to be seen.
Civic Learning, Science, and Structural Racism Evans, Kiameesha R.; Gusmano, Michael K.
The Hastings Center report,
January‐February 2021, 2021-Jan, 2021-01-00, 20210101, Letnik:
51, Številka:
S1
Journal Article
Recenzirano
Vaccine hesitancy is a major public health challenge, and racial disparities in the acceptance of vaccines is a particular concern. In this essay, we draw on interviews with mothers of Black male ...adolescents to offer insights into the reasons for the low rate of vaccination against the human papillomavirus among this group of adolescents. Based on these conversations, we argue that increasing the acceptance of HPV and other vaccines cannot be accomplished merely by providing people with more facts. Instead, we must address the pervasive racial discrimination in the United States that undermines trust in social institutions, including the health care system. In the short term, it may be helpful to increase the number of clinicians of color working in the health system, but more fundamental changes are required. The U.S. must adopt and implement policies that dismantle structural racism if it hopes to produce greater trust and community‐oriented thinking on behalf of people who have been exploited for centuries.
The development of technologies for gene editing in the wild has the potential to generate tremendous benefit, but also raises important concerns. Using some form of public deliberation to inform ...decisions about the use of these technologies is appealing, but public deliberation about them will tend to fall back on various forms of heuristics to account for limited personal experience with these technologies. Deliberations are likely to involve narrative reasoning—or reasoning embedded within stories. These are used to help people discuss risks, processes, and fears that are otherwise difficult to convey. In this article, we identify three forms of collective narrative that are particularly relevant to debates about modifying genes in the wild. Our purpose is not to privilege any particular narrative, but to encourage people involved in deliberations to make these narratives transparent. Doing so can help guard against the way some narratives—referred to here as “crafted narratives”—may be manipulated by powerful elites and concentrated economic interests for their own strategic ends.
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