User fees, self-selection and the poor in Bangladesh.
(17/4330)
The widespread uncontrolled introduction of user fees in any developing country is likely to have a disastrous impact on poorer patients. Furthermore, traditional targeting schemes aimed at their exemption are often expensive, difficult to administer and ineffective at reaching those in greatest need. This research study examines how user fees can raise revenue and target poorer patients, under the right market conditions, without resorting to costly targeting schemes. The authors draw their findings from case studies of cost recovery in the health and population sectors in Bangladesh. The mechanism suggested in the paper is to use self-selection. It is argued that under certain market conditions poorer patients will choose the health-care option that is appropriate to their means. They will thus identify themselves as poor without having to be selected or tested by an independent authority. This self-selection allows the relevant authorities to cross-subsidize their market choice by over-charging the non-poor in other segments of the market. (+info)
Explaining educational differences in mortality: the role of behavioral and material factors.
(18/4330)
OBJECTIVES: This study examined the role of behavioral and material factors in explaining educational differences in all-cause mortality, taking into account the overlap between both types of factors. METHODS: Prospective data were used on 15,451 participants in a Dutch longitudinal study. Relative hazards of all-cause mortality by educational level were calculated before and after adjustment for behavioral factors (alcohol intake, smoking, body mass index, physical activity, dietary habits) and material factors (financial problems, neighborhood conditions, housing conditions, crowding, employment status, a proxy of income). RESULTS: Mortality was higher in lower educational groups. Four behavioral factors (alcohol, smoking, body mass index, physical activity) and 3 material factors (financial problems, employment status, income proxy) explained part of the educational differences in mortality. With the overlap between both types of factors accounted for, material factors were more important than behavioral factors in explaining mortality differences by educational level. CONCLUSIONS: The association between educational level and mortality can be largely explained by material factors. Thus, improving the material situation of people might substantially reduce educational differences in mortality. (+info)
Socioeconomic status and morbidity in the last years of life.
(19/4330)
OBJECTIVES: This study evaluated the effect of socioeconomic status, as characterized by level of education, on morbidity and disability in the last years of life. METHODS: The analysis used data from the National Health Interview Survey (1986-1990), with mortality follow-up through December 1991. RESULTS: Among 10,932 decedents 50 years or older at baseline interview, educational attainment was inversely associated with long-term limitation of activity, number of chronic conditions, number of bed days, and days of short hospital stay during the year preceding the interview. CONCLUSIONS: Decedents with higher socioeconomic status experienced lower morbidity and disability and better quality of life even in their last years of life. (+info)
Poverty area residence and changes in depression and perceived health status: evidence from the Alameda County Study.
(20/4330)
BACKGROUND: Previous evidence from the Alameda County Study indicated that residential area has an independent effect on risk for mortality, adjusting for a variety of important individual characteristics. The current research examined the effect of poverty area residence on risk for developing depressive symptoms and decline in perceived health status in a sample of 1737. METHODS: Data were from a longitudinal population-based cohort. Multiple logistic regression analyses were used. RESULTS: Age- and sex-adjusted risk for incident high levels of depressive symptoms in 1974 was higher for poverty area residents (odds ratio [OR] 2.14; confidence interval [CI]: 1.49-3.06). Those reporting excellent/good health in 1965 were at higher risk for having fair/poor health in 1974 if they lived in a poverty area (age- and sex-adjusted OR 3.30; CI: 2.32-4.71). Independent of individual income, education, smoking status, body mass index, and alcohol consumption, poverty area residence remained associated with change in outcome variables. CONCLUSION: These results further support the hypothesis that characteristics of place affect health conditions and health status. (+info)
Income inequality and health: pathways and mechanisms.
(21/4330)
The relationship between income and health is well established: the higher an individual's income, the better his or her health. However, recent research suggests that health may also be affected by the distribution of income within society. We outline the potential mechanisms underlying the so-called relative income hypothesis, which predicts that an individual's health status is better in societies with a more equal distribution of incomes. The effects of income inequality on health may be mediated by underinvestment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital; and the harmful psychosocial effects of invidious social comparisons. (+info)
Low income, race, and the use of mammography.
(22/4330)
OBJECTIVE: To describe national trends in mammography use by race and income and to test whether higher use of mammography among low-income African American women than low-income white women can be explained by health insurance coverage, usual place of health care, or place of residence. DATA SOURCES/STUDY SETTING: Data from five years of the National Health Interview Survey spanning the period 1987-1994. STUDY DESIGN: Trends in the percentage of women 50-64 years of age with a mammogram within the past two years were analyzed by race and income. Data for 1993-1994 were pooled, and with logistic regression analysis, variation in use of recent mammography for low-income women was investigated. Independent variables are age, race, family income, education, health insurance coverage, place of usual source of health care, metropolitan residence, and geographic region. DATA COLLECTION/EXTRACTION METHODS: The National Health Interview Survey is a cross-sectional national survey conducted by the National Center for Health Statistics. Data are collected through household interviews. [Editor's note: in keeping with HSR policy, the term black is used to conform to its use in the surveys studied. In other references to race, the term African American is used.] PRINCIPAL FINDINGS: Among women 50-64 years of age use of recent mammograms increased rapidly between 1987 and 1991 for all groups of women, and between 1991 and 1994 the increases slowed. However, increases between 1991 and 1994 have been more rapid among low-income black women than among low-income white women. In 1993-1994, low-income black women were about one-third more likely than low-income white women to report mammography within the past two years. This difference could not be explained by health insurance coverage, usual source of health care, metropolitan status, or region of residence. CONCLUSIONS: These results, which provide some evidence of success for screening programs targeted to the poor, raise the question of why low-income black women appear to be to more likely than low-income white women to have benefited from recent efforts to promote mammography. Continued evaluation of mammography programs focused on women who are underserved as well as the monitoring of trends and variations in service use by race and income are needed. (+info)
Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries.
(23/4330)
OBJECTIVE: To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration. STUDY DESIGN: We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing. PRINCIPAL FINDINGS: Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and services, but spent less than the other groups on prescription drugs and dental care-services not covered by Medicare. CONCLUSIONS: While Medicaid provides substantial protection for some lower-income Medicare beneficiaries, out-of-pocket health care spending continues to be a substantial burden for most of this population. Medicare reform discussions that focus on shifting more costs to beneficiaries should take into account the dramatic costs of health care already faced by this vulnerable population. (+info)
Pressures on safety net access: the level of managed care penetration and uninsurance rate in a community.
(24/4330)
OBJECTIVE: To examine the effects of managed care penetration and the uninsurance rate in an area on access to care of low-income uninsured persons and to compare differences in access between low-income insured and uninsured persons across these different market areas. DATA SOURCES: Primarily the Community Tracking Study household survey. Other market-level data were obtained from the Community Tracking Study physician survey, American Hospital Association annual survey of hospitals, Area Resource File, HCFA Administrative Data, Bureau of Primary Care data on Community Health Centers. STUDY DESIGN: Individuals are grouped based on the level of managed care penetration and uninsurance rate in the site where they reside. Measures of managed care include overall managed care penetration in the site, and the level of Medicaid managed care penetration in the state. Uninsurance rate is defined as the percentage of people uninsured in the site. Measures of access include the percentage with a usual source of care, percentage with any ambulatory care use, and percentage of persons who reported unmet medical care needs. Estimates are adjusted to control for other confounding factors, including both individual and market-level characteristics. DATA COLLECTION: A survey, primarily telephoned, of households concentrated in 60 sites, defined as metropolitan statistical areas and nonmetropolitan areas. PRINCIPAL FINDINGS: Access to care for low-income uninsured persons is lower in states with high Medicaid managed care penetration, compared to uninsured persons in states with low Medicaid managed care penetration. Access to care for low-income uninsured persons is also lower in areas with high uninsurance rates. The "access gap" (differences in access between insured and uninsured persons) is also larger in areas with high Medicaid managed care penetration and areas with high uninsurance rates. CONCLUSIONS: Efforts to achieve cost savings under managed care may result in financial pressures that limit cross-subsidization of care to the medically indigent, particularly for those providers who are heavily dependent on Medicaid revenue. High demand for care (as reflected in high uninsurance rates) may further strain limited resources for indigent care, further limiting access to care for uninsured persons. (+info)