Abstract Objectives This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d’Azur ...(PACA); and identifies the factors that contribute to disparities in access to care within and among these regions. Methods To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization – bypass surgery and angioplasty – among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization. Results In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals. Conclusions Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.
In this article, we review state policy responses to the COVID‐19 pandemic and argue that they were driven primarily by partisan politics. Preliminary evidence suggests that the party affiliation of ...a state's Governor was the most important factor shaping the nature and timing of the response. In particular, we find that Republican Governors were less likely than their Democratic counterparts to issue stay‐at‐home orders and, when they did issue them, were slower to do so. This finding is consistent with a recent trend in U.S. health policy toward vertical partisan coalitions in which state leaders align their policies with national party leaders even when those decisions may not be in the best interest of their states or supported by a majority of their constituents. In this case, however, since President Trump's response to the outbreak has been inconsistent, many Republican Governors appear to be aligning their COVID‐19 responses with the national party's perceived rhetorical and electoral enhancing goals of personal freedom and economic growth/recovery, rather than with President.
To determine whether the use of the emergency department (ED) for nonurgent care reflects poor access to community-based primary care providers (PCPs).
Using a survey of ED patients, insurance claims ...data, and administrative records identifying demographic factors, we analyzed the use of the ED in an impoverished area of Brooklyn, New York.
We examined original survey data to investigate the extent to which residents of northern and central Brooklyn use EDs for nonemergencies and whether these patients have access to PCPs. We used data from health insurers operating in northern and central Brooklyn, and New York state hospital ED visit data to investigate the factors influencing ED visits for ambulatory care-sensitive conditions (ACSCs). Logistic regression was used to identify characteristics that predict ED visits not resulting in admission for ACSCs.
Of 11,546 patients that completed our survey, the presenting complaint was self-described as emergent by 57%, 30% had no PCP, and 19% reported no health insurance coverage. Using health insurance plan encounter data, only 15 % of patients had seen any provider within 1 week of the ED visit. Insurance type, age, gender, race/ethnicity, and socioeconomic status of area of residence influence the likelihood of these ED visits.
Correlating data from 3 sources, we suggest that the expansion of insurance under the Affordable Care Act may not be sufficient to reduce ED use for nonurgent conditions.
The CARES Act of 2020 allocated provider relief funds to hospitals and other providers. We investigate whether these funds were distributed in a way that responded fairly to COVID-19–related medical ...and financial need. The US health care system is bifurcated into the “haves” and “have nots.” The health care safety net hospitals, which were already financially weak, cared for the bulk of COVID-19 cases. In contrast, the “have” hospitals suffered financially because their most profitable procedures are elective and were postponed during the COVID-19 outbreak.
To obtain relief fund data for each hospital in the United States, we started with data from the HHS website. We use the RAND Hospital Data tool to analyze how fund distributions are associated with hospital characteristics.
Our analysis reveals that the “have” hospitals with the most days of cash on hand received more funding per bed than hospitals with fewer than 50 days of cash on hand (the “have nots”).
Despite extreme racial inequities, which COVID-19 exposed early in the pandemic, the federal government rewards those hospitals that cater to the most privileged in the United States, leaving hospitals that predominantly serve low-income people of color with less.
The Tax Cuts and Jobs Act (TCJA) eliminated the ACA's “shared responsibility payment,” which penalized those who failed to comply with the requirement to purchase health insurance. In this article ...the authors explain efforts in several states to respond to this change by adopting individual health insurance mandates at the state level. Although there are good reasons to think that states may be reluctant to consider establishing their own mandates, New Jersey, the District of Columbia, and Vermont quickly joined Massachusetts in establishing such measures in 2018. In 2019 California and Rhode Island enacted state-level mandates. Four other states—Maryland, Connecticut, Hawaii, and Washington—formally considered mandates but have not enacted them. The authors compare the policy debates among these states and one other state, New York, which has not seen a legislative proposal for a mandate despite its strong support for the ACA. Their analysis explores the dynamics within the US federal system when a key component of a complex and politically salient national initiative is eliminated and states are left with many policy, political, and administrative questions of what to do next.
Patients As Partners: The Authors Reply Gusmano, Michael K; Maschke, Karen J; Solomon, Mildred Z
Health affairs Web exclusive,
06/2019, Letnik:
38, Številka:
6
Journal Article
This paper documents changes in infant mortality (IM) rates in São Paulo, Brazil, between 2003 and 2013 and examines the association among neighborhood characteristics and IM. We investigate the ...extent to which increased use of health care services and improvements in economic and social conditions are associated with reductions in IM. Using data from the Brazilian Census and the São Paulo Secretaria Municipal da Saúde/SMS, we conducted a longitudinal analysis of panel data in all 96 districts of São Paulo for every year between 2003 and 2013. Our regression model includes district level measures that reflect economic, health care and social determinants of IM. We find that investments in health care have contributed to lower IM rates in the city, but the direct effect of increased spending is most evident for people living in São Paulo's middle- and high-income neighborhoods. Improvements in social conditions were more strongly associated with IM declines than increases in the use of health care among São Paulo's low-income neighborhoods. To reduce health inequalities, policies should target benefits to lower-income neighborhoods. Subsequent research should document the consequences of recent changes in Brazil's economic capacity and commitment to public health spending for population health.
Objectives
To determine the level of neighbourhood inequalities in infant mortality (IM) rates in the urban core of four world cities and to examine the association between neighbourhood‐level income ...and IM. We compare our findings with those published in 2004 to better understand how these city health systems have evolved.
Methods
We compare IM rates among and within the four cities using data from four periods: 1988–1992; 1993–1997; 2003–2008 and 2012–2016. Using a maximum‐likelihood negative binomial regression model that controls for births, we predict the relationship between neighbourhood‐level income and IM.
Results
IM rates have declined in all four cities. Neighbourhood‐level income is statistically significant for New York and, for the two most recent periods, in Paris. In contrast, there is no significant relationship between neighbourhood income and IM in London or Tokyo.
Conclusions
Despite programmes to reduce IM inequalities at national and local levels, these persist in New York. Until the early part of this century, none of the other cities experienced a relationship between neighbourhood income and IM, but growing income inequalities within Paris have changed this situation.
Policy implications
Policy‐makers in these cities should focus on better understanding the social and economic factors associated with neighbourhood inequalities in IM.
Highlights
Manhattan has a strong negative relationship linking neighbourhood income and infant mortality (IM).
Paris, since 2003, has a negative relationship between neighbourhood income and IM.
Inequalities in IM rates in cities are influenced by national health and social policies.
Reducing neighbourhood inequalities requires targeted public health approaches.
This book analyzes policy fights about what counts as good evidence of safety and effectiveness when it comes to new health care technologies in the United States and what political decisions mean ...for patients and doctors. Medical technologies often promise to extend and improve quality of life but come with many questions: Are they safe and effective? Are they worth the cost? When should they be allowed on the market, and when should Medicare, Medicaid, and private insurance companies be required to pay for drugs, devices, and diagnostic tests? Using case studies of disputes about the value of mammography screening; genetic testing for disease risk; brain imaging technologies to detect biomarkers associated with Alzheimer’s disease; cell-based therapies; and new, expensive drugs, Maschke and Gusmano illustrate how scientific disagreements about what counts as good evidence of safety and effectiveness are often swept up in partisan fights over health care reform and battles among insurance and health care companies, physicians, and patient advocates. Debating Modern Medical Technologies: The Politics of Safety, Effectiveness, and Patient Access reveals stakeholders’ differing values and interests regarding patient choice, physician autonomy, risk assessment, government intervention in medicine and technology assessment, and scientific innovation as a driver of national and global economies. It will help readers to understand the nature and complexity of past and current policy disagreements and their effects on patients.
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