A model of factors determining levels of public support for health care policy in the United States

Public preferences for policy are formed in a little-understood process that is not adequately described by traditional economic theory of choice. In this paper I suggest that U.S. aggregate support for health reform can be modeled as tradeoffs among a small number of behavioral values and the stage of policy development. The theory underlying the model is based on Samuelson, et al.'s (1986) work and Wilke's (1991) elaboration of it as the Greed/Efficiency/Fairness (GEF) hypothesis of motivation in the management of resource dilemmas, and behavioral economics informed by Kahneman and Thaler's prospect theory. ^ The model developed in this paper employs ordered probit econometric techniques applied to data derived from U.S. polls taken from 1990 to mid-2003 that measured support for health reform proposals. Outcome data are four-tiered Likert counts; independent variables are dummies representing the presence or absence of operationalizations of each behavioral variable, along with an integer representing policy process stage. Marginal effects of each independent variable predict how support levels change on triggering that variable. Model estimation results indicate a vanishingly small likelihood that all coefficients are zero and all variables have signs expected from model theory. ^ Three hypotheses were tested: support will drain from health reform policy as it becomes increasingly well-articulated and approaches enactment; reforms appealing to fairness through universal health coverage will enjoy a higher degree of support than those targeted more narrowly; health reforms calling for government operation of the health finance system will achieve lower support than those that do not. Model results support the first and last hypotheses. Contrary to expectations, universal health care proposals did not provide incremental support beyond those targeted to “deserving” populations—children, elderly, working families. In addition, loss of autonomy (e.g. restrictions on choice of care giver) is found to be the “third rail” of health reform with significantly-reduced support. When applied to a hypothetical health reform in which an employer-mandated Medical Savings Account policy is the centerpiece, the model predicts support that may be insufficient to enactment. These results indicate that the method developed in the paper may prove valuable to health policy designers. ^

Racial and ethnic disparities in diabetes mellitus and hypertension: Influence of income and insurance status in a cross-sectional study of the United States

Racial/ethnic disparities in diabetes mellitus (DM) and hypertension (HTN) have been observed and explained by socioeconomic status (education level, income level, etc.), screening, early diagnosis, treatment, prognostic factors, and adherence to treatment regimens. To the author's knowledge, there are no studies addressing disparities in hypertension and diabetes mellitus utilizing Hispanics as the reference racial/ethnic group and adjusting for sociodemographics and prognostic factors. This present study examined racial/ethnic disparities in HTN and DM and assessed whether this disparity is explained by sociodemographics. To assess these associations, the study utilized a cross-sectional design and examined the distribution of the covariates for racial/ethnic group differences, using the Pearson Chi Square statistic. The study focused on Non-Hispanic Blacks since this ethnic group is associated with the worst health outcomes. Logistic regression was used to estimate the prevalence odds ratio (POR) and to adjust for the confounding effects of the covariates. Results indicated that except for insurance coverage, there were statistically significant differences between Non-Hispanic Blacks and Non-Hispanic Whites, as well as Hispanics with respect to study covariates. In the unadjusted logistic regression model, there was a statistically significant increased prevalence of hypertension among Non-Hispanic Blacks compared to Hispanics, POR 1.36, 95% CI 1.02-1.80. Low income was statistically significantly associated with increased prevalence of hypertension, POR 0.38, 95% CI 0.32-0.46. Insurance coverage, though not statistically significant, was associated with an increase in the prevalence of hypertension, p>0.05. Concerning DM, Non-Hispanic Blacks were more likely to be diabetic, POR 1.10, 95% CI 0.85-1.47. High income was statistically significantly associated with decreased prevalence of DM, POR 0.47, 95% CI 0.39-0.57. After adjustment for the relevant covariates, the racial disparities between Hispanics and Non-Hispanic Blacks in HTN was removed, adjusted prevalence odds (APOR) 1.21, 95% CI 0.88-1.67. In this sample, there was racial/ethnic disparity in hypertension but not in diabetes mellitus between Hispanics and Non-Hispanic Blacks, with disparities in hypertension associated with socioeconomic status (family income, education, marital status) and also by alcohol, physical activity and age. However, race, education and BMI as class variables were statistically significantly associated with hypertension and diabetes mellitus p<0.0001. ^

Effects of health disparities on Helicobacter pylori infection among children on the US-Mexico border

The objective of this study is to determine whether health disparities influence the odds of developing H. pylori infections among the children enrolled in the Pasitos Cohort Study on the US-Mexico border. The study variables were the number of prenatal care visits, ways of transportation, car in household, location of health services and insurance coverage. The study recruited eligible pregnant women to complete baseline questionnaires. Every six months after the birth of the child, infection status is measure by the 13-C urea breath test. Results indicate that having medical insurance consistently decreases the odds of being infected. Children with mothers who went to a private physician had decreased odds of infection compared to those utilizing public clinics, and having a car in the household increased the odds of infection. Limitations include bias due to loss to follow-up and the transient nature of the infection.^

The medical malpractice insurance "crises" and federal medical malpractice tort reform: Collection and analysis of bills passed by the United States House of Representatives from 1995--2005

There have been three medical malpractice insurance "crises" in the United States over a time spanning roughly the past three decades (Poisson, 2004, p. 759-760). Each crisis is characterized by a number of common features, including rapidly increasing medical malpractice insurance premiums, cancellation of existing insurance policies, and a decreased willingness of insurers to offer or renew medical malpractice insurance policies (Poisson, 2004, p. 759-760). Given the recurrent "crises," many sources argue that medical malpractice insurance coverage has become too expensive a commodity—one that many physicians simply cannot afford (U.S. Department of Health and Human Services [HHS], 2002, p. 1-2; Physician Insurers Association of America [PIAA], 2003, p. 1; Jackiw, 2004, p. 506; Glassman, 2004, p. 417; Padget, 2003, p. 216). ^ The prohibitively high cost of medical liability insurance is said to limit the geographical areas and medical specializations in which physicians are willing to practice. As a result, the high costs of medical liability insurance are ultimately said to affect whether or not people have access to health care services. ^ In an effort to control the medical liability insurance crises—and to preserve or restore peoples' access to health care—every state in the United States has passed "at least some laws designed to reduce medical malpractice premium rates" (GAO, 2003, p.5-6). More recently, however, the United States has witnessed a push to implement federal reform of the medical malpractice tort system. Accordingly, this project focuses on federal medical malpractice tort reform. This project was designed to investigate the following specific question: Do the federal medical malpractice tort reform bills which passed in the House of Representatives between 1995 and 2005 differ in respect to their principle features? To answer this question, the text of the bills, law review articles, and reports from government and private agencies were analyzed. Further, a matrix was compiled to concisely summarize the principle features of the proposed federal medical malpractice tort reform bills. Insight gleaned from this investigation and matrix compilation informs discussion about the potential ramifications of enacting federal medical malpractice tort reform legislation. ^

The mark of a good healer: Examining health care behaviors in the Vietnamese community

The purpose of this study was to conduct a descriptive, exploratory analysis of the utilization of both traditional healing methods and western biomedical approaches to health care among members of the Vietnamese community in Houston, Texas. The first goal of the study was to identify the type(s) of health care that the Vietnamese use. The second goal was to highlight the numerous factors that may influence why certain health care choices are made. The third goal of this study was to examine the issue of preference to determine which practices would be used if limiting factors did not exist. ^ There were 81 participants, consisting of males and females who were 18 years or older. The core groups of participants were Vietnamese students from the University of Houston-Downtown and volunteer staff members from VN TeamWork. Asking the students and staff members to recommend others for the study used the snowball method of recruiting additional participants. ^ Surveys and informed consents were in English and Vietnamese. The participants were given the choice to take the surveys face-to-face or on their own. Surveys consisted of structured questions with predetermined choices, as well as, open-ended questions to allow more detailed information. The quantitative and qualitative data were coded and entered into a database, using SPSS software version 15.0. ^ Results indicated that participants used both traditional (38.3%) and biomedical (59.3%) healing, with 44.4% stating that it depended on the illness as to treatment. Coining was the most used traditional healing method, clearly still used by all ages. Coining was also the method most used when issues regarding fear and delayed western medical treatment were involved. It was determined that insurance status, more than household income, guided health care choices. A person's age, number of years spent in the United States, age at migration, and the use of certain traditional healing methods like coining all played a role in the importance of the health care practitioner speaking Vietnamese. The most important finding was that 64.2% of the participants preferred both traditional and western medicine because both methods work. ^

Crossing the border for dental care: Factors related to dental health among the south Texas border region

Objectives. The purpose of this thesis is to understand the underlying socioeconomic characteristics affecting dental insurance coverage, yearly dental visits, and factors related to visiting a dentist in Mexico among border region residents. Methods. Using data from the Border Epidemiological Study of Aging, dental utilization in the previous 12 months, dental visits to Mexico, and dental insurance (proxy) were calculated utilizing logistic regression. Three different models were utilized for the dependent variables adjusting for diverse socioeconomic characteristics such as gender, age, marital status, income, education, years of residence in the United States (for immigrants), English proficiency, general health status, employment and dental insurance. Results. After adjustment, diverse variables were significant for the three different models calculated. Conclusion. Although the Mexican health market constitutes a viable option for dental services for border residents, dental insurance and dental yearly visits were lower in this region when compared to national averages. ^

Physician coding for mental illness reimbursement and the need for mental health parity

Many patients with anxiety and depression initially seek treatment from their primary care physicians. Changes in insurance coverage and current mental parity laws, make reimbursement for services a problem. This has led to a coding dilemma for physicians seeking payment for their services. This study seeks to determine first the frequency at which primary care physicians use alternative coding, and secondly, if physicians would change their coding practices, provided reimbursement was assured through changes in mental parity laws. A mail survey was sent to 260 randomly selected primary care physicians, who are family practice, internal medicine, and general practice physicians, and members of the Harris County Medical Society. The survey evaluated the physicians' demographics, the number of patients with psychiatric disorders seen by primary care physicians, the frequency with which physicians used alternative coding, and if mental parity laws changed, the rate at which physicians would use a psychiatric illness diagnosis as the primary diagnostic code. The overall response rate was 23%. Only 47 of the 59 physicians, who responded, qualified for the study and of those 45% used a psychiatric disorder to diagnose patients with a primary psychiatric disorder, 47% used a somatic/symptom disorder, and 8% used a medical diagnosis. From the physicians who would not use a psychiatric diagnosis as a primary ICD-9 code, 88% were afraid of not being reimbursed and 12% were worried about stigma or jeopardizing insurability. If payment were assured using a psychiatric diagnostic code, 81% physicians would use a psychiatric diagnosis as the primary diagnostic code. However, 19% would use an alternative diagnostic code in fear of stigmatizing and/or jeopardizing patients' insurability. Although the sample size of the study design was adequate, our survey did not have an ideal response rate, and no significant correlation was observed. However, it is evident that reimbursement for mental illness continues to be a problem for primary care physicians. The reformation of mental parity laws is necessary to ensure that patients receive mental health services and that primary care physicians are reimbursed. Despite the possibility of improved mental parity legislation, some physicians are still hesitant to assign patients with a mental illness diagnosis, due to the associated stigma, which still plays a role in today's society. ^

Findings of the University of Texas Health Science Center at San Antonio's Dental School pilot mobile van program in Laredo, Texas

Lack of access to oral health care frequently affects those of lower socio-economic level; individuals in this group experience more dental decay, and the caries experience is more likely to be untreated. Inadequate dental care access may be attributed to exclusion that is due to income, geography, age, race or ethnicity. Objective: The present study aims were to: (1) determine how oral disease prevalence and access to dental services in four US-Mexico Border unincorporated low socioeconomic settlements identified as colonias compare to each other and Laredo, Texas, and (2) determine if insurance status affects dental care access and/or disease prevalence. Methods: A secondary analysis of data from a retrospective chart review of 672 patients attending a Mobile Dental Van Program in the Webb County colonias. Demographic information, (ethnicity, age, gender, insurance coverage and colonia site), dental visits within past year, insurance status, presence of dental sealants, prevalence of untreated dental decay (caries), and presence of gum disease (gingivitis and periodontitis) were extracted. Pearson's chi-square tests (χ2) were computed to compare the prevalence of these outcomes between colonias and Laredo and their potential association with insurance status. Results: For 6 - 11 year olds, dental visits in the past year were lower for colonias (39%), than Laredo (58.5%) (p<0.002). Caries prevalence was higher for colonias (56.6%), than Laredo (37.1%) (p<0.001). Gum disease prevalence was higher in colonias (73%), than in Laredo (21.4%) (p<0.001). No significant differences were noted for caries (χ2=1.73; p<0.188) and gum disease (χ2=0.0098; p<0.921) by patient's insurance status. For adults 36 - 64 years of age, dental visits in the past year were lower in colonias (22.4%), than Laredo (36.3%) (p<0.001). Caries prevalence was higher for colonias (78.3%), than Laredo (54.0%) (p<0.001). Gum disease prevalence was also higher among colonias (91.3%) than Laredo (61.3%) (p<0.001). No significant differences were noted for caries (χ2=0.0010; p<0.975) and gum disease (χ2=0.0607; p<0.805) by patient's insurance status. Conclusion: Colonia residents seeking dental care at a Mobile Dental Van Program in Webb County have significantly higher prevalence of oral disease regardless of insurance status.^

A study of the determinants of the utilization of preventive health care service among Chicanos

This study examines the individual and health care system determinants of two types of preventive health care practice behaviors, having a routine physical exam or a preventive dental exam, in the past year among Chicanos in the Southwestern United States. The study utilizes the Health System Model, developed by Aday and Andersen in 1974, to analyze the relative effect of education, income and occupation on the use of discretionary health care, controlling for other individual and health care system determinants.^ The study is based on a sample of 4,111 Mexican origin adults, drawn from the Hispanic Health and Nutrition Examination Survey (HHANES). This sample is representative of Mexican American residing in the Southwestern United States.^ The study tests the hypothesis that education is the most important social class predictor of preventive health care practice behavior. The fully elaborated model tests the hypothesis that individual determinants alone are insufficient to explain the use of preventive health care services among Chicanos.^ The study found that education and income are statistically significant social class indicators only as it relates to having a preventive dental exam. Education is not the most important social class predictor of either preventive health care practice behavior. Health care system determinants are key predictors of both behaviors. Need, as measured by self-perceived health status of teeth and gender, is as important a determinant as having dental insurance coverage as it relates to having a preventive dental exam. Implications for health programs to effectively reach Chicano target groups and remove access barriers to their use of discretionary health care services are discussed. ^

STRATEGIES FOR THE TRANSFER OF APPROPRIATE TECHNOLOGY TO DEVELOPING COUNTRIES: THE IMPLEMENTATION AND DEVELOPMENT OF ENVIRONMENTAL HEALTH PROGRAMS IN TUNISIA

This dissertation focuses on Project HOPE, an American medical aid agency, and its work in Tunisia. More specifically this is a study of the implementation strategies of those HOPE sponsored projects and programs designed to solve the problems of high morbidity and infant mortality rates due to environmentally related diarrheal and enteric diseases. Several environmental health programs and projects developed in cooperation with Tunisian counterparts are described and analyzed. These include (1) a paramedical manpower training program; (2) a national hospital sanitation and infection control program; (3) a community sewage disposal project; (4) a well reconstruction project; and (5) a solid-waste disposal project for a hospital.^ After independence, Tunisia, like many developing countries, encountered several difficulties which hindered progress toward solving basic environmental health problems and prompted a request for aid. This study discusses the need for all who work in development programs to recognize and assess those difficulties or constraints which affect the program planning process, including those latent cultural and political constraints which not only exist within the host country but within the aid agency as well. For example, failure to recognize cultural differences may adversely affect the attitudes of the host staff towards their work and towards the aid agency and its task. These factors, therefore, play a significant role in influencing program development decisions and must be taken into account in order to maximize the probability of successful outcomes.^ In 1969 Project HOPE was asked by the Tunisian government to assist the Ministry of Health in solving its health manpower problems. HOPE responded with several programs, one of which concerned the training of public health nurses, sanitary technicians, and aids at Tunisia's school of public health in Nabeul. The outcome of that program as well as the strategies used in its development are analyzed. Also, certain questions are addressed such as, what should the indicators of success be, and when is the time right to phase out?^ Another HOPE program analyzed involved hospital sanitation and infection control. Certain generic aspects of basic hospital sanitation procedures were documented and presented in the form of a process model which was later used as a "microplan" in setting up similar programs in other Tunisian hospitals. In this study the details of the "microplan" are discussed. The development of a nation-wide program without any further need of external assistance illustrated the success of HOPE's implementation strategies.^ Finally, although it is known that the high incidence of enteric disease in developing countries is due to poor environmental sanitation and poor hygiene practices, efforts by aid agencies to correct these conditions have often resulted in failure. Project HOPE's strategy was to maximize limited resources by using a systems approach to program development and by becoming actively involved in the design and implementation of environmental health projects utilizing "appropriate" technology. Three innovative projects and their implementation strategies (including technical specifications) are described.^ It is advocated that if aid agencies are to make any progress in helping developing countries basic sanitation problems, they must take an interdisciplinary approach to progrm development and play an active role in helping counterparts seek and identify appropriate technologies which are socially and economically acceptable. ^

AN EMPIRICAL ESTIMATION OF MEDICAL AND NON-MEDICAL INPUTS IN THE PRODUCTION OF CARDIO-RESPIRATORY PHYSICAL HEALTH STATUS

The purpose of this study was to examine, in the context of an economic model of health production, the relationship between inputs (health influencing activities) and fitness.^ Primary data were collected from 204 employees of a large insurance company at the time of their enrollment in an industrially-based health promotion program. The inputs of production included medical care use, exercise, smoking, drinking, eating, coronary disease history, and obesity. The variables of age, gender and education known to affect the production process were also examined. Two estimates of fitness were used; self-report and a physiologic estimate based on exercise treadmill performance. Ordinary least squares and two-stage least squares regression analyses were used to estimate the fitness production functions.^ In the production of self-reported fitness status the coefficients for the exercise, smoking, eating, and drinking production inputs, and the control variable of gender were statistically significant and possessed theoretically correct signs. In the production of physiologic fitness exercise, smoking and gender were statistically significant. Exercise and gender were theoretically consistent while smoking was not. Results are compared with previous analyses of health production. ^

Funding the utilization of community health workers in Texas

Community health workers (CHWs) are volunteers or paid members of communities that perform outreach, patient assistance, health education, and assist in navigation of healthcare system amongst other duties. The utilization of CHWs in hospital and community setting provides health benefits to their communities while reducing cost to the overall healthcare system. ^ The general population of Texas lacks adequate access to primary care. An important indicator of such a crisis is excessive usage of emergency department services in Texas, especially by the large minority population within the state. Also, unmanaged chronic diseases have been shown to be correlated with the excessive usage of emergency services. According to a recent survey of 25 Houston metropolitan area hospitals, almost 54% of the ER visits could have been resolved in primary care settings. A Galveston based study also indicated that the ER usage was higher amongst African-Americans and Latinos. Meanwhile, 28.5% of the total ER visits were made by Latinos from the surrounding areas (Begley et al., 2007). There is substantial evidence present which indicates enormous cost-savings that CHWs have produced in Texas and nationwide through reduction in unnecessary ER visits along with better management of chronic diseases (Fedder et al, 2003). ^ This paper provides an analysis regarding the need and importance for sustainable and stable sources of funding for Community health workers (CHWs) in Texas utilizing Kingdon's model of Agenda Setting as framework. The policy analysis is also aimed at reporting on the policy process and actions taken by Children at Risk to address this critical issue. Children at Risk, a Houston based advocacy organization, has created a legislative proposal that calls on the Texas Health and Human Commission to apply for a Medicaid §§1115 waiver to provide sustainable sources of funding for CHWs, Rep. John Zerwas sponsored HB 2244 bill and it was filed on March 3, 2011. The bill would affect the use of CHWs in Texas in two ways: 1) through the establishment and operation of a program designed to train and educate CHWs 2) by creating a statewide training and certification advisory committee. The advisory committee is required in the bill to submit recommendations for providing sustainable funding and employment for CHWs. The HB 2244 failed to move out of the House Public Health committee. However, HB2244 was amended into HB 2610 introduced by Representative Guillen. The House Bill 2610 is geared towards establishing a community-based navigator program in order to assist individuals applying for public assistance through the Internet. The House Bill 2610 was signed by the Governor and will be effective September 1, 2011.^

Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

The effects of health changes on projections of health service needs for the elderly population of the United States

The 1982–1994 National Long-Term Care Surveys indicate an accelerating decline in disability among the U.S. elderly population, suggesting that a 1.5% annual decline in chronic disability for elderly persons is achievable. Furthermore, many risk factors for chronic diseases show improvements, many linked to education, from 1910 to the present. Projections indicate the proportion of persons aged 85–89 with less than 8 years of education will decline from 65% in 1980 to 15% in 2015. Health and socioeconomic status trends are not directly represented in Medicare Trust Fund and Social Security Administration beneficiary projections. Thus, they may have different economic implications from projections directly accounting for health trends. A 1.5% annual disability decline keeps the support ratio (ratio of economically active persons aged 20–64 to the number of chronically disabled persons aged 65+) above its 1994 value, 22:1, when the Hospital Insurance Trust Fund was in fiscal balance, to 2070. With no changes in disability, projections indicate a support ratio in 2070 of 8:1—63% below a cash flow balance.

Consumer Driven Health Care: An Examination of the Disadvantages to Low Income Employees

As health care costs for companies continue to rise, more organizations are considering a consumer driven health plan option with the goal to engage employees so that they make better health care decisions. Although consumer driven health plan options present advantages to the employer and some employee groups, low income employees are negatively impacted by this option. Two major disadvantages include missed care and out of pocket obligations. This capstone reviews the current literature on consumer driven health care and discusses the disadvantages to low income employees. It also provides strategies and recommendations to employers who are considering a consumer driven health option plan to minimize the disadvantages to low income employees.