Public Health Care Financing Research Articles

Conflicts Between Religious or Spiritual Beliefs and Pediatric Care: Informed Refusal, Exemptions, and Public Funding

Although respect for parents' decision-making authority is an important principle, pediatricians should report suspected cases of medical neglect, and the state should, at times, intervene to require medical treatment of children. Some parents' reasons for refusing medical treatment are based on their religious or spiritual beliefs. In cases in which treatment is likely to prevent death or serious disability or relieve severe pain, children's health and future autonomy should be protected. Because religious exemptions to child abuse and neglect laws do not equally protect all children and may harm some children by causing confusion about the duty to provide medical treatment, these exemptions should be repealed. Furthermore, public health care funds should not cover alternative unproven religious or spiritual healing practices. Such payments may inappropriately legitimize these practices as appropriate medical treatment.

Does healthcare financing converge? Evidence from eight OECD countries

This study investigated the convergence of healthcare financing across eight OECD countries during 1960-2009 for the first time. The panel stationary test incorporating both shapes of multiple structural breaks (i.e., sharp drifts and smooth transition shifts) and cross-sectional dependence was used to provide reliable evidence of convergence in healthcare financing. Our results suggested that the public share of total healthcare financing in eight OECD countries has exhibited signs of convergence towards that of the US. The convergence of healthcare financing not only reflected a decline in the share of public healthcare financing in these eight OECD countries but also exhibited an upward trend in the share of public healthcare financing in the US over the period of 1960-2009.

Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform

BackgroundMedicaid is a major source of public health care financing for pregnant women and deliveries in the United States. Starting in 2014, some states will extend Medicaid to thousands of previously uninsured, low-income women. Given this changing landscape, it is important to have a baseline of current levels of Medicaid financing for births in each state. This article aims to 1) provide up-to-date, multiyear data for all states, the District of Columbia, and Puerto Rico and 2) summarize issues of data comparability in view of increased interest in program performance and impact assessment. MethodsWe collected 2008–2010 data on Medicaid births from individual state contacts during the winter of 2012–2013, systematically documenting sources and challenges. FindingsIn 2010, Medicaid financed 48% of all births, an increase of 19% in the proportion of all births covered by Medicaid in 2008. Percentages varied among states. Numerous data challenges were found. Conclusions/Implications for Research and PolicyConsistent adoption of the 2003 birth certificate in all states would allow the National Center for Health Statistics Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.

COPING WITH THE ECONOMIC CONSEQUENCES OF ILL HEALTH IN INDONESIA

We assess the economic risk of ill health for households in Indonesia and the role of informal coping strategies. Using household panel data from the Indonesian socio-economic household survey (Susenas) for 2003 and 2004, and applying fixed effects Poisson models, we find evidence of economic risk from illness through medical expenses. For the poor and the informal sector, ill health events impact negatively on income from wage labour, whereas for the non-poor and formal sector, it is income from self-employed business activities which is negatively affected. However, only for the rural population and the poor does this lead to a decrease in consumption, whereas the non-poor seem to be able to protect current household spending. Borrowing and drawing on family network and buffers, such as savings and assets, seem to be key informal coping strategies for the poor, which may have negative long-term effects. While these results suggest scope for public intervention, the economic risk from income loss for the rural poor is beyond public health care financing reforms. Rather, formal sector employment seems to be a key instrument for financial protection from illness, by also reducing income risk.

Private Health Care Sector in Russia:Present State and Development Prospects

The private sector which has emerged in the Russian health care system has become a competitor to the public one and has pulled a part of effective demand of the middle class. It has developed out of the public health care financing system. Depending on the policy of the state towards modernization of health care, the private sector can continue to grow as an alternative to the public one, but it can be a tool of modernization and an organic part of an integrated health care system.

Reforms Are Needed To Increase Public Funding And Curb Demand For Private Care In Israel’s Health System

Historically, the Israeli health care system has been considered a high-performance system, providing universal, affordable, high-quality care to all residents. However, a decline in the ratio of physicians to population that reached a modern low in 2006, an approximate ten-percentage-point decline in the share of publicly financed health care between 1995 and 2009, and legislative mandates that favored private insurance have altered Israel's health care system for the worse. Many Israelis now purchase private health insurance to supplement the state-sponsored universal care coverage, and they end up spending more out of pocket even for services covered by the entitlement. Additionally, many publicly paid physicians moonlight at private facilities to earn more money. In this article I recommend that Israel increase public funding for health care and adopt reforms to address the rising demand for privately funded care and the problem of publicly paid physicians who moonlight at private facilities.

The “Weisbrod Quadrilemma” Revisited: Insurance Incentives on New Health Technologies

The effect of insurance expansion on the diffusion of new technologies is not a well-understood phenomenon. Arguably, an expansion of insurance coverage provides a motivation for R&D investment in medical technologies. Although risk pooling through insurance gives rise to greater affordability for existing treatments and becomes a volume driver of new treatments, it may also influence provider reimbursement through a monopsony purchaser effect and related cost control measures. However, the impact that insurance has on technology availability and R&D investment, and more generally on the adoption of new technologies, remains an unexplored empirical question. This paper presents evidence of a link between insurance and technology diffusion using OECD panel data and taking advantage of a dynamic specification structure. Our empirical estimates indicate that higher degrees of private expenditure on health care correlate with higher levels of R&D in health care, consistent with the hypothesis forwarded by Weisbrod that increasing insurance coverage boosts technology adoption. However, our findings also suggest that increasing public funding of health care appears to lower technological adoption, which is, of course, consistent with the exercising of monopsony power and an objective of cost containment.

Sustainability of universal health coverage in Italy: a modelling study

BackgroundItaly and the Eurozone are in their largest ever financial depression. Several, often contradictory, public economic and financial stability emergency interventions are being introduced, whose ultimate effects on public and private health spending and on the sustainability of universal health coverage are difficult to predict. We assessed their magnitude and effect on sustainability of publicly funded health care and universal coverage. The Italian Economic and Stability Reform Program 2011–14 assumes that: gross domestic product will grow exponentially between 2011 and 2014, at a rate of 3·18% per year compared with 3·29% in the period 1997–2010; the public component of health-care financing will not grow in the period 2011–14 compared with growth of 0·82% per year for 1997–2010; and growing expenditure for non-health applications—for example, sovereign debt service, pensions, unemployment subsidies, sovereign debt fiscal compact, and deficit reduction—is not expected to affect health financing and universal coverage. MethodsWe analysed the Italian Economic and Stability Reform Program 2011–2014, which incorporates Eurostat and Organisation for Economic Co-operation and Development health and economic data and guidelines, and developed a quantitative synthetic sustainability index σ based on simple partial and absolute differential equations to account for simultaneous variation in total health financing, its public component, and nominal gross domestic product. We tested historical trends and projections adjusted with the sustainability index σ with standard population Pearson's product-moment correlation coefficients. FindingsThe Italian Economic and Stability Reform Program 2011–2014 focuses its public health-care financing interventions on freezing the exponential growth of public health financing propensity (the ratio between public health financing and the nominal gross domestic product; presently roughly 7% of gross domestic product), while adjusting the growth rate of public health financing (exponential growth rate=2·83%, r=0·98) to that of gross domestic product (exponential growth rate=3·18%, r=1·00). Under the assumptions of the Economic and Stability Reform Program, the sustainability index σ is in the financially sustainable range (–1<σ<0). If growth of gross domestic product between 2011 and 2014 is insufficient—as it has been for January, to June, 2012 (–2·40%)—then the assumptions of the Program will not hold and the index will increase to more than 1, making universal health coverage financially unsustainable. InterpretationHealth professionals should advise Italian and Eurozone national budget planners and financial health regulators before unselective public health financing and provision shortages following the European Fiscal Compact Convergence and Stability Parameters incorporated in the Italian Economic and Stability Reform Program damage universal health coverage in Italy. FundingUniversity of Milano-Bicocca, University of Bergamo.

Public health care financing in Nigeria: Which way forward?

The way a country finances its health care system is a key determinant of the health of its citizenry. Selection of an adequate and efficient method(s) of financing in addition to organizational delivery structure for health services is essential if a country is set to achieve its national health objective of providing health for all. Health care in Nigeria is financed by tax revenue, out-of-pocket payments, donor funding, and health insurance (social and community). However, achieving successful health care financing system continues to be a challenge in Nigeria. This article examines the different financing mechanisms that have been used in Nigeria, including the National Primary Health Care Development Fund proposed for increasing the resource allocation to primary health care. It draws on available and relevant literature to provide an overview and the state of public health care financing in Nigeria. This article concludes by recommending the need for Nigeria to explore and strengthen other mechanisms of health system and shift focus from out-of-pocket payments, address the issues that have undermined public health care financing in Nigeria, improve on evidence-based planning, and prompt implementation of the National Health Bill when signed into law.

Can Competition Improve Outcomes in UK Health Care? Lessons from the Past Two Decades

UK governments of all political colours have sought to improve productivity in health care by introducing pro-competitive reforms in the National Health Service (NHS) during the last two decades. The first wave of reform operated from 1991 to 1997. The second wave was introduced in England only in the mid 2000s. In 2010, further reform in England, intended to increase the extent of competition, was proposed by the Coalition administration. But the effect of competition on productivity in health care and in particular on the quality of health care remains a contested issue. This paper reviews the evidence, focusing on robust and recent evidence, on the use of competition as a mechanism for improving quality. The consensus is that competition will increase quality in health care, but that institutional details matter. Given this, we end by discussing whether the current plans to make the buyers of care family doctors and other professionals and to allow some local price variation are likely to be beneficial in the UK context of full public funding for health care.

Democratizing health. Consumer groups in the policy process

DEMOCRATIZING HEALTH. CONSUMER GROUPS IN THE POLICY PROCESS Edited by Hans Lofgren, Evelyne de Leeuw and Michael Leahy 2011 Edward Elgar. ISBN 978 1 84844 784 4 10.1071/AHv36n3_BR1One of the greatest strengths of this book is the quite remarkable spread of contributors from across the globe. The three editors - all from our own Deakin University - are to be congratulated for managing to get such a broad international array of authors and country experiences. And these matter for such a book. They matter first because the issue of democratising health is a genuinely international one; second in any country's agenda for pursuing such democratisation there are lessons to be learned from other countries; and third, as it turns out, experiences across countries vary quite a bit.I enjoyed the book and found it a most useful addition to the literature in this field. In reviewing it, however, I need to declare a particular bias with respect to democratising health. I see citizens as being those who would be involved in such a process and I prefer to draw a clear distinction between citizens and consumers. (I will return to that issue shortly.)The book, for an edited volume with 16 chapters, is very readable. That is quite something when it covers such a range of very different countries from the USA to Malaysia, from Austria to Australia.The book opens with the following statement from the editors:'This book examines the extent to which consumer groups engage in the development of policy affecting their members' health and health care. Such engagement may be referred to as the 'democratisation of health' but, as the contributions to this book show, there are considerable differences between national contexts as to what this means, both in theory and in practice.' (p. 1)The editors suggest that there are two streams to democracy 'the liberal or the social stream' but that, whichever is adopted, democracy 'is perceived rightly or wrongly as the only form of government capable of giving due recognition to human dignity'. (p. 2)Beyond the introductory chapter, Milewa discusses health activism in the age of governance and interestingly concludes that 'health activist groups exist only because their aims have not been met in the context of the political, bureaucratic and medical status quo.' (p. 27)The majority of the other chapters have a specific country focus. For Malaysia, Barraclough and Kai Lit show how, in the wake of the adoption of neo-liberal ideology and policies, including privatisation, the role of consumer groups changed. 'Their role in monitoring 'value for money' and quality of care was intensified by the rapid growth of private hospitals and the more intensive use of medical technology' (p. 164). It was then perhaps inevitable that they became embroiled in 'an ideological challenge to the government's stated goals of reducing the public financing of health care and privatising the public agencies responsible for its delivery' (p. 164).Church and Armstrong worry about the role of citizens in Canada generally, but also specifically with respect to healthcare where they claim that consumer groups have increasingly been driven into 'an unholy alliance with private corporate concerns' (p. 205) and they call for 'a greater sense of organic citizenship' (p. 205) in Canada.There are two chapters on the USA, one by Fox and Lambertson is quite despairing of the role of health consumers to date - but they take heart from the Obama reforms that their voice can make a difference; they end on a positive note, 'If a strong consumer voice continues to develop...this nascent voice [can] gradually weave its way into the fabric of American political dialogue' (p. …

A case study and state of science review: private versus public healthcare financing.

Medicare is a popular program in Canada that offers universal access to medically-necessary healthcare services for all Canadians through a public insurance plan in each province. In spite of its popularity, healthcare privatization has been debated, often over concerns about wait times for select healthcare services. A case report focused on the 2005 Supreme Court’s response to the “Chaoulli v. Quebec” challenge of the Quebec law banning the purchase of private health insurance for publicly-insured services is presented, along with findings from a state of science review to determine if there would be any benefit from adopting the United States model of private health insurance. This review reveals private health insurance would have significant negative implications, especially by creating inequity in healthcare access for low-income groups. Further study is needed to determine whether Canada’s publicly-funded healthcare system would benefit in any way from increased private financing.

Improved Evidence Will Support Sound Decision Making but Will Not Solve the Problem of Cost Containment in Oncology

TO THE EDITOR: In his recent contribution, Caplan 1 suggested four shifts in thinking about the ethics of health care to strengthen the role of evidence in current debates on cost containment. We agree with the statement of Caplan that “evidence is not determinative about what we ought to do.” However, we argue that it is already possible to determine more clearly the kind of evidence that is needed for decision making than was done in the article. Moreover, it seems crucial to clarify the limits of evidence with regards to setting the limits of public health care funding fairly. Caplan 1 envisaged the decision making between patients and physicians as a process in which oncologists provide guidance for prudent choices, especially regarding tough choices in end-stage cancer care. We sympathize with such an approach to deliberative or shared decision making. However, current clinical research does not often provide the evidence needed for discussions about benefits and burdens of “another round of chemotherapy.” 1 Although clinical researchers published rich data regarding the improvement of progression-free survival that did not often translate in the same way to a longer overall survival, 2 there is a scarcity of data on the burdens of such treatment and its effect on the quality of life, especially with respect to the last phase of life. Such patient-orientated research is a prerequisite for “offering an opinion informed by evidence” in situations in which a significant number of patients with advanced cancer understandably enough ask for anything available at the end of their disease trajectory. 3 The need for the right data indicates that value judgments become relevant long before the interpretation of evidence, as seemed to be suggested by Caplan. 1 Examples for normative relevant decisions when data are generated and published are the well-known practices of selective reporting of favorable results and decisions about the study design (ie, noninferior studies, exclusion criteria, and study duration) and the choice of patient-relevant end points or the early stoppage of trials. Value judgments also come into play when systematic reviews are generated that need to synthesize study findings and often play a crucial role in coverage decisions (eg, in the purposes of the Patient

Impact of Tissue Plasminogen Activator on the Neurovascular Unit: From Clinical Data to Experimental Evidence

About 15 million strokes occur each year worldwide. As the number one cause of morbidity and acquired disability, stroke is a major drain on public health-care funding, due to long hospital stays followed by ongoing support in the community or nursing-home care. Although during the last 10 years we have witnessed a remarkable progress in the understanding of the pathophysiology of ischemic stroke, reperfusion induced by recombinant tissue-type plasminogen activator (tPA-Actilyse) remains the only approved acute treatment by the health authorities. The objective of the present review is to provide an overview of our present knowledge about the impact of tPA on the neurovascular unit during acute ischemic stroke.

POLITICAL TRANSFORMATION IN CENTRAL/EASTERN EUROPE AND FORMER SOVIET REPUBLICS AND ITS EFFECT ON HEALTHCARE SYSTEM AND ITS OUTCOMES

During the period of communism countries in Central and Eastern Europe, both those being republics of the former Soviet Union, and those existing independently from former USSR structures, followed the same model of healthcare, named after its creator Semashko’s model. The main assumption of this solution was to provide the same and possibly the most complete medical services to all citizens. Beginning from 1989, the political system in the region of the world started to shift towards the market economy, although the pace of changes was different, faster in the Central Europe, and slower in the former Soviet Union. Healthcare sector in the analyzed countries had to go in hand with political transformation. Besides, it became obvious that public financing of healthcare must be related to gross domestic product, so countries with lower income were forced to limit the availability of certain medical services. The publication analyses changes in healthcare sector in a number of countries that went through the political transformation and their effect on main health indicators. It compares a few key indicators, like life expectancy, in the very beginning of transformation and several years later. Apart from pure epidemiological data we presented trends in density of healthcare professionals per 100 000 population, as well as focusing on primary care.

Health-related Quality of Life is Associated with Diabetic Complications, but not with Short-term Diabetic Control in Primary Care

Type 2 diabetes mellitus is of increasing healthcare concern worldwide, with incidence rising, complications leading to significant morbidity and mortality, posing strain on public healthcare funding. Health-related quality of life of diabetic patients is increasingly being recognised as "the ultimate goal of all health interventions". The aim of our study was to identify the quality of life predictors of diabetic patients in primary care. This study was conducted in 8 public primary care polyclinics from SingHealth Polyclinics. We carried out a cross-sectional, questionnaire-based survey on 699 diabetic patients, administered by medical students on a systematic sample of patients during their routine visit. Multiple regression analysis was used to investigate the socio-demographic and clinical characteristics as predictors of quality of life, measured by the Short Form 36 Health Survey (SF-36) and the EQ-5D self-report questionnaire. Higher quality of life in diabetic patients is associated with younger age, male gender, employed status, higher educational level and exercise. Lower quality of life is associated with comorbidities and diabetic complications. Short-term glycaemic control as measured by HbA1c did not correlate with quality of life. Most interestingly, confidence in doctor and satisfaction in clinic were related to better quality of life. Health-related quality of life is adversely associated with symptomatic complications of diabetes mellitus, but not with short-term diabetic control. This suggests that the diabetic patient may not appreciate the impact of good diabetic control immediately on his or her health-related quality of life. More effort should be invested into patient education of the importance of glycaemic control to prevent these long-term complications.

Medical Tourism: Reverse Subsidy for the Elite

The medical tourism sector in India has attracted global attention, given its phenomenal growth in the past decade. India is second only to Thailand in the number of medical tourists that it attracts every year. Estimates indicate that the medical tourism market in India could grow from $310 million in 2005 to $2 billion by 2012. These figures are significant when contrasted with India's overall health care expenditure - $10 billion in the public sector and $50 billion in the private sector. Factors that have contributed to this growth include the relative proficiency in English among health care providers and the cost effectiveness of medical procedures in India. Generally, most procedures in Indian hospitals cost a quarter (or less) of what they would cost in developed countries. The expansion of medical tourism has also been fueled by the growth of the private medical sector in India, a consequence of the neglect of public health by the government. India has one of the poorest records in the world regarding public financing and provisioning of health care. A growing driver of medical tourism is the attraction of facilities in India that offer access to assisted reproductive care technologies. Ironically, this is in sharp contrast with the acute neglect of the health care needs of Indian women. The Indian government is vigorously promoting medical tourism by providing tax concessions and by creating an environment enabling it to thrive. However, there is a distinct disjunction between the neglect of the health care needs of ordinary Indians and public policy that today subsidizes the health care of wealthy foreigners.

Pursuing Health-Care Reform: The Promise and the Pitfalls

In developing health care reform proposals, it is important to recognize that our health care system has evolved over a long period of time and reflects values in which Americans believe deeply - values like pluralism and entrepreneurial-ism, consumer choice, limited government, and low taxation. Any major reforms will assault, or at least do some violence to, these values. Nevertheless there's a gathering consensus that reform of the fractured health care system to which Americans have grown accustomed is necessary, based on two overriding concerns: an uninsured population of approximately 35 million people, more than half of whom are adults holding full-time jobs; and medical care costs that continue to rise more than twice as rapidly as the consumer price index. These problems have festered for over a decade. The obvious change in the equation is a restive middle class, concerned about the uncertainty of its health insurance arrangements, and a new President who has staked his political future on making these arrangements more secure. President Clinton brings to this task a strong belief that federal policy should create a framework that encompasses all health insurance arrangements, not just those that are sponsored by government and financed through taxation. This represents a fundamental change in national health policy. During twelve years of Republican rule, the federal government defined its responsibility in the health care field only as far as the publicly financed programs, largely Medicare and Medicaid, without any responsibility to create a framework under which the whole system would operate. Clearly there is a direct link between public and private financing of health care through cost-shifting, which has increased over the years. The President proposes to transform the system that is today dominated by private decision-making and financing to one that places the federal and state governments in far more central regulatory roles in relation to how resources are allocated and how the system functions.

The convergence of health care financing structures: empirical evidence from OECD-countries

The convergence/divergence of health care systems between countries is an interesting facet of the health care system research from a macroeconomic perspective. In this paper, we concentrate on an important dimension of every health care system, namely the convergence/divergence of health care financing (HCF). Based on data from 22 OECD countries in the time period 1970-2005, we use the public financing ratio (public financing in % of total HCF) and per capita public HCF as indicators for convergence. By applying different concepts of convergence, we find that HCF is converging. This conclusion also holds when we look at smaller subgroups of countries and shorter time periods. However, we find evidence that countries do not move towards a common mean and that the rate of convergence is decreasing over time.

Financing equitable access to antiretroviral treatment in South Africa

BackgroundWhile South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020.MethodsThe costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices.ResultsThe annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget.ConclusionsResponding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a “resource for democracy” or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans.