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3.
Am J Public Health ; 109(11): 1497-1500, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31536401

RESUMO

Recently there has been a surge in political attention to Medicare for all, the latest chapter in a long history of conflict over national health insurance in the United States. This essay places the current Medicare for all debate in historical perspective.My aim is to illuminate past struggles over single-payer reform, explore the genesis and evolution of Medicare, and analyze the implications for contemporary health politics of the public and private insurance arrangements developed by the United States over the past century.The history of US health reform provides critical lessons for understanding the enduring appeal of single-payer models as well as the formidable political obstacles to transforming Medicare for all from an aspiration into a legislative reality.


Assuntos
Medicare/tendências , National Health Insurance, United States/tendências , Política , Sistema de Fonte Pagadora Única/tendências , Humanos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Estados Unidos
6.
J Clin Anesth ; 51: 98-107, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30099349

RESUMO

STUDY OBJECTIVE: Our aim was to quantify the extent to which the distribution of patients among payers and changes to the payers' policies has influenced the market of surgery among hospitals in a relatively rural state. DESIGN: Retrospective cohort study. SETTING: Iowa Hospital Association data analyzed were from 2007 through 2016 for the N = 121 hospitals with at least one case performed that included a major therapeutic procedure. MEASUREMENTS: We used five categories of payer (e.g., Medicare), five categories of patient age (e.g., 18 to 64 years), and three categories of patient residence location (e.g., neither from the county of the hospital nor from a county contiguous to the county of the hospital). MAIN RESULTS: Sorting hospitals in descending sequence of numbers of surgical cases, depending on year, the top 10% of hospitals performed 58.4% to 59.2% of the cases. Increases in numbers of cases among patients with commercial insurance increased the heterogeneity among hospitals in numbers of surgical cases (P < 0.0001). However, the magnitude of the effect was very small, with an estimated relative marginal effect on the overall Gini index of only 0.9% ±â€¯0.2% (SE). Increases in numbers of cases of patients with Medicare insurance reduced the heterogeneity in numbers of cases among hospitals (P < 0.0001), but also with very small magnitude (-0.9% ±â€¯0.2%). In contrast, factors encouraging patient travel contributed to larger hospitals becoming larger, and smaller hospitals becoming smaller (3.9% ±â€¯0.7%, P < 0.0001). CONCLUSIONS: We found the absence of a substantive effect of insurance and national US payment systems on the relative distribution of surgical cases among hospitals. Anesthesia groups should focus on payer and payment reform in terms of their effects on payment rates (e.g., average payment per relative value guide unit), not on their potential effects on hospital caseloads.


Assuntos
Setor de Assistência à Saúde/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Hospitais Rurais/economia , Humanos , Lactente , Recém-Nascido , Iowa , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , National Health Insurance, United States/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/economia , Estados Unidos , Carga de Trabalho/economia , Adulto Jovem
7.
Soc Work Health Care ; 57(10): 834-850, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30136904

RESUMO

PURPOSE: The purpose of this study is to examine the prevalence of depression and physical and psychosocial factors associated with depression among adults with Type 2 Diabetes Mellitus (T2DM). METHODS: The sample included 421 patients with T2DM at a Federally Qualified Healthcare Center in a southern state. The Patient Health Questionnaire (PHQ-9) was used to measure the severity of depression. RESULTS: The multiple logistic regression analyses revealed that the likelihood of depression increased as the level of pain increased and as the level of ambulation difficulties increased. The likelihood of depression increased as the number of traumatic events increased and as the number of SES-related stressors increased. Expectedly, the likelihood of depression decreased as levels of self-esteem increased. CONCLUSIONS: The findings support that health care providers developing care plans for individuals with diabetes need to include assessments and interventions that address both the physical and psychosocial needs of patients.


Assuntos
Depressão , Diabetes Mellitus Tipo 2 , Adulto , Idoso , Idoso de 80 Anos ou mais , Depressão/complicações , Depressão/epidemiologia , Depressão/fisiopatologia , Depressão/psicologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Humanos , Acontecimentos que Mudam a Vida , Masculino , Pessoa de Meia-Idade , National Health Insurance, United States , Fatores Socioeconômicos , Estresse Psicológico , Estados Unidos/epidemiologia , Adulto Jovem
8.
Bioethics ; 32(9): 577-584, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29718562

RESUMO

The Trump Administration's recent attempts to repeal the Affordable Care Act have reignited long-running debates surrounding the nature of justice in health care provision, the extent of our obligations to others, and the most effective ways of funding and delivering quality health care. In this article, I respond to arguments that individualist systems of health care provision deliver higher-quality health care and promote liberty more effectively than the cooperative, solidaristic approaches that characterize health care provision in most wealthy countries apart from the United States. I argue that these claims are mistaken and suggest one way of rejecting the implied criticisms of solidaristic practices in health care provision they represent. This defence of solidarity is phrased in terms of the advantages solidaristic approaches to health care provision have over individualist alternatives in promoting certain important personal liberties, and delivering high-quality, affordable health care.


Assuntos
Reembolso de Seguro de Saúde/tendências , Patient Protection and Affordable Care Act/normas , Assistência à Saúde/normas , Humanos , National Health Insurance, United States/tendências , Estados Unidos
9.
Pediatrics ; 141(Suppl 3): S259-S265, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29496977

RESUMO

Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.


Assuntos
Doença Crônica/terapia , Assistência à Saúde/tendências , Planejamento em Saúde/tendências , Política de Saúde/tendências , National Health Insurance, United States/tendências , Assistência Centrada no Paciente/tendências , Criança , Assistência Integral à Saúde/economia , Assistência Integral à Saúde/tendências , Assistência à Saúde/economia , Planejamento em Saúde/economia , Humanos , National Health Insurance, United States/economia , Assistência Centrada no Paciente/economia , Estados Unidos/epidemiologia
11.
Med Care Res Rev ; 75(3): 384-393, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29148331

RESUMO

Many insurers incurred financial losses in individual markets for health insurance during 2014, the first year of Affordable Care Act mandated changes. This analysis looks at key financial ratios of insurers to compare profitability in 2014 and 2013, identify factors driving financial performance, and contrast the financial performance of health insurers operating in state-run exchanges versus the federal exchange. Overall, the median loss of sampled insurers was -3.9%, no greater than their loss in 2013. Reduced administrative costs offset increases in medical losses. Insurers performed better in states with state-run exchanges than insurers in states using the federal exchange in 2014. Medical loss ratios are the underlying driver more than administrative costs in the difference in performance between states with federal versus state-run exchanges. Policy makers looking to improve the financial performance of the individual market should focus on features that differentiate the markets associated with state-run versus federal exchanges.


Assuntos
Trocas de Seguro de Saúde/economia , Seguradoras/economia , National Health Insurance, United States/economia , National Health Insurance, United States/estatística & dados numéricos , Patient Protection and Affordable Care Act/economia , Planos Governamentais de Saúde/economia , Planos Governamentais de Saúde/estatística & dados numéricos , Trocas de Seguro de Saúde/estatística & dados numéricos , Humanos , Seguradoras/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estados Unidos
13.
Policy Polit Nurs Pract ; 18(2): 61-71, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28728524

RESUMO

The U.S. presidential election of 2016 accentuated the divided perspectives on the Patient Protection and Affordable Care Act of 2010, commonly known as Obamacare. The perspectives included a pledge from then candidate Donald J. Trump to "repeal and replace on day one"; Republican congressional leaders' more temperate suggestions in the first weeks of the Trump administration to "repair" the Affordable Care Act (ACA); and President Trump's February 5, 2017 statement-16 days after inauguration-that a Republican replacement for the ACA may not be ready until late 2017 or 2018. The swirling rhetoric, media attention, and the dizzying rate of U.S. health and payment reforms both within and outside of the ACA makes it difficult for nurses, both United States and globally, to discern which health policy issues are grounded in the ACA and which aspects reflect payer-driven "volume to value" reimbursement changes. Moreover, popular and controversial elements of the ACA-for example, the clause that prohibits insurance carriers to deny coverage to those with preexisting health conditions and the more controversial individual mandate that bears Supreme Court support as a constitutional provision-are paired in ways that might be unclear to those unfamiliar with nuances of insurance rate determination. To support nurses' capacity to maximize their impact on health policy, this overview distills the 906-page ACA into major themes and describes payment reform legislation and initiatives that are external to the ACA. Understanding the political and societal forces that affect health care policy and delivery is necessary for nurses to effectively lead and advocate for the best interests of their patients.


Assuntos
Custos de Cuidados de Saúde/tendências , Reembolso de Seguro de Saúde/tendências , Patient Protection and Affordable Care Act , Assistência à Saúde/tendências , Humanos , Medicaid , Medicare , National Health Insurance, United States/tendências , Estados Unidos
15.
Aliment Pharmacol Ther ; 45(9): 1201-1212, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28271521

RESUMO

BACKGROUND: Highly effective direct antiviral agents (DAAs) for hepatitis C virus (HCV) were introduced recently. Their utilisation has been limited by high cost and low access to care. AIM: To describe the effect of DAAs on HCV treatment and cure rates in the United States Veterans Affairs (VA) national healthcare system. METHODS: We identified all HCV antiviral treatment regimens initiated from 1 January 1999 to 31 December 2015 (n = 105 369) in the VA national healthcare system, and determined if they resulted in sustained virological response (SVR). RESULTS: HCV antiviral treatment rates were low (1981-6679 treatments/year) in the interferon era (1999-2010). The introduction of simeprevir and sofosbuvir in 2013 and ledipasvir/sofosbuvir and paritaprevir/ombitasvir/ritonavir/dasabuvir in 2014 were followed by increases in annual treatment rates to 9180 in 2014 and 31 028 in 2015. The number of patients achieving SVR was 1313 in 2010, the last year of the interferon era, and increased 5.6-fold to 7377 in 2014 and 21-fold to 28 084 in 2015. The proportion of treated patients who achieved SVR increased from 19.2% in 1999 and 36.0% in 2010 to 90.5% in 2015. Within 2015, monthly treatment rates ranged from 727 in July to 6868 in September correlating with the availability of funds for DAAs. CONCLUSIONS: DAAs resulted in a 21-fold increase in the number of patients achieving HCV cure. Treatment rates in 2015 were limited primarily by the availability of funds. Further increases in funding and cost reductions of DAAs in 2016 suggest that the VA could cure the majority of HCV-infected Veterans in VA care within the next few years.


Assuntos
Antivirais/uso terapêutico , Hepatite C/tratamento farmacológico , Quimioterapia Combinada/tendências , Feminino , Hepacivirus/genética , Hepatite C/sangue , Hepatite C/virologia , Humanos , Masculino , Pessoa de Meia-Idade , National Health Insurance, United States , RNA Viral/sangue , Estados Unidos , United States Department of Veterans Affairs
19.
Fam Med ; 48(2): 95-9, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26950779

RESUMO

BACKGROUND: Changes in the landscape of medical practice in recent years, accelerated since the passage of the Affordable Care Act (ACA) in 2010, have led to further fragmentation of primary care and disruption of the doctor-patient relationship for many millions of Americans. Patients face escalating costs of care and restricted choice of physician and hospital in a largely corporatized health care system. The goals of family medicine are compromised by these system trends. The ACA is unsustainable for a number of reasons, including lack of price controls and cost containment, unaffordable costs for patients and taxpayers, widespread underinsurance, and massive administrative waste. Financing reform through single-payer national health insurance will bring a fairer system of universal coverage for comprehensive care of higher quality at less cost, while enabling a renaissance of family medicine and primary care as an expanding base of our health care system.


Assuntos
Medicina de Família e Comunidade/organização & administração , Reforma dos Serviços de Saúde , National Health Insurance, United States , Patient Protection and Affordable Care Act , Atenção Primária à Saúde/organização & administração , Previsões , Acesso aos Serviços de Saúde , Humanos , Cobertura do Seguro , Patient Protection and Affordable Care Act/tendências , Relações Médico-Paciente , Sistema de Fonte Pagadora Única , Estados Unidos
20.
J Trauma Acute Care Surg ; 80(5): 764-75; discussion 775-7, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26958790

RESUMO

BACKGROUND: Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS: Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS: A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS: While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.


Assuntos
Afro-Americanos/estatística & dados numéricos , Medicina de Emergência/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Militares , National Health Insurance, United States/estatística & dados numéricos , Adolescente , Adulto , Feminino , Hospitais Gerais/economia , Hospitais Militares/economia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios , Estados Unidos/epidemiologia , Ferimentos e Lesões/etnologia , Ferimentos e Lesões/cirurgia , Adulto Jovem
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