Implementation Of New Mexico's 'No Behavioral Health Cost Sharing' Law: A Qualitative Study.

Out-of-pocket spending is a long-standing challenge for privately insured people. New Mexico passed the first US law prohibiting private insurers from applying cost sharing to behavioral health treatment, effective January 1, 2022. We examined the perceptions of key informants, including clinicians, insurers, and state officials, about implementing the No Behavioral Health Cost Sharing law to explore how it might affect downstream outcomes such as spending and access. The law was viewed favorably and implemented without much difficulty. Clinicians noted widespread positive impacts, particularly for those needing intensive treatment. However, they worried about workforce capacity and the exclusion of people covered under self-insured employer plans, which are exempt from state regulation under the Employee Retirement Income Security Act (ERISA) of 1974. Insurers found the law to be in alignment with their organizational goals, but they expressed concern about the administrative burden caused by increased reviews of claims, and some were monitoring for unintended consequences (for example, waste and fraud) that could lead to increased premiums. Engagement strategies were needed to inform eligible members and facilitate enrollment in eligible plans. The law provides a potential model for states to improve access to behavioral health care, but impacts may be limited by factors such as workforce, awareness, and federal ERISA constraints.

Redefining the "Public Option": Lessons from Washington State and New Mexico.

Policy Points States are enacting a host of policy initiatives designed to reduce the number of Americans without health insurance. Policymakers and policy analysts need to examine whether this "laboratory of federalism" is producing ideas that can and should be replicated on a national scale. This article evaluates reform efforts in two states: Washington state, which enacted what its policymakers call a "public option" and New Mexico, which failed in its effort to enact a Medicaid buy-in. Some common themes emerge. First, without federal funding, state efforts to aid the uninsured remain limited. Second, the gap between commercial and public insurance reimbursement rates poses an additional significant obstacle. Washington state was able to overcome these obstacles by enacting a law (called Cascade Care) which imposes public sector reimbursement rates in a commercial insurance market (the state's ACA Marketplace). This quasi- or redefined public option could become a politically viable model for federal policymakers.

Effects of the Affordable Care Act on Vascular Patient Amputation Rates in Arkansas.

BACKGROUND: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease. METHODS: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data. RESULTS: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05). CONCLUSIONS: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.

Supplemental health insurance in the Colombian managed care system: Adverse or advantageous selection?

The aim of this article is to estimate the type of selection that exists in the supplemental health insurance market in Colombia where compulsory coverage is implemented through managed care competition. We build a panel database that combines individuals' information from the Ministry of Health and a database provided by two private health insurers. We perform the correlation test for consumption of health services frequency and supplemental coverage. Following Fang et al. (2008), we condition the estimation on health controls that are available to the econometrician but not to insurers. In both cases we obtain a positive correlation, suggesting that adverse selection predominates. In order to rule out some moral hazard effects, we estimate the correlation between previous frequency of healthcare service consumption and supplemental insurance purchase. The positive correlation obtained is robust to the inclusion of controls for diagnosis implemented by health insurers, suggesting that despite some risk selection strategies, they are not protected from adverse selection. We conclude that some subsidies to supplemental coverage purchase would lower public expenditure in Colombia.

Physician Attitudes Toward Adult Vaccines and Other Preventive Practices, United States, 2012.

OBJECTIVES: We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits. METHODS: We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians. RESULTS: We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of "Welcome to Medicare" and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month. CONCLUSIONS: Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

Health reform and the US Virgin Islands: high-need-limited impact.

OBJECTIVES: There are 4.1 million residents living in the US territories, which is more than the combined population of many US states, yet the territories and their citizens are often overlooked from a policy perspective, because most individual territories are relatively small, geographically isolated, and have been treated differently than the states historically. This tendency to fall beneath the radar is clear in the realm of health policy, especially in the area of insurance coverage. This article provides an initial assessment of the potential impact of health reform on the US Virgin Islands (USVI) and, in light of this assessment, considers how the results of a USVI household survey conducted in 2003 and 2009 might be used as a baseline for future monitoring of the impact of national reform. METHODS: A study by the Virgin Island's Bureau of Economic Research, Office of the Governor, and the University of Minnesota, was conducted in 2003 and 2009. The Virgin Islands Health Insurance telephone Surveys were random digit dial landline telephone surveys of households in the USVI. A stratified sample was drawn to produce precise estimates of insurance coverage for the USVI as a whole and for the 3 islands separately. RESULTS: Almost one-third of the residents (28.7%) in the Virgin Islands were uninsured in 2009. This rate is twice the US average (15.4%) and significantly higher than the uninsured rate of 24.1% when a similar survey was last conducted the Virgin Islands in 2003. CONCLUSIONS: The Patient Protection and Affordable Care Act of 2010 provides special funding to the territories through a mix of increased Medicaid caps for each territory and the provision of premium subsidies through newly established health insurance exchanges to low-income populations. However, the Affordable Care Act's Medicaid expansions to newly eligible adults--primarily adults without children--are limited to current eligibility levels in the territories, which is $5,500 in annual income for adult coverage in the USVI. Within these abbreviated parameters, the Medicaid expansion can go so far only toward mitigating uninsurance among the lowest income groups in the territories. With certain low-income childless adults overlooked, the Affordable Care Act does not fully address the high need for affordable health insurance coverage in the territories.

United States-Mexico cross-border health insurance initiatives: Salud Migrante and Medicare in Mexico.

While U.S. health care reform will most likely reduce the overall number of uninsured Mexican-Americans, it does not address challenges related to health care coverage for undocumented Mexican immigrants, who will remain uninsured under the measures of the reform; documented low-income Mexican immigrants who have not met the five-year waiting period required for Medicaid benefits; or the growing number of retired U.S. citizens living in Mexico, who lack easy access to Medicare-supported services. This article reviews two promising binational initiatives that could help address these challenges-Salud Migrante and Medicare in Mexico; discusses their prospective applications within the context of U.S. health care reform; and identifies potential challenges to their implementation (legal, political, and regulatory), as well as the possible benefits, including coverage of uninsured Mexican immigrants, and their integration into the U.S. health care system (through Salud Migrante), and access to lower-cost Medicare-supported health care for U.S. retirees in Mexico (Medicare in Mexico).

United States-Mexico cross-border health insurance initiatives: Salud Migrante and Medicare in Mexico / Iniciativas transfronterizas de seguro de salud entre México y los Estados Unidos: Salud Migrante y Medicare en México

While U.S. health care reform will most likely reduce the overall number of uninsured Mexican-Americans, it does not address challenges related to health care coverage for undocumented Mexican immigrants, who will remain uninsured under the measures of the reform; documented low-income Mexican immigrants who have not met the five-year waiting period required for Medicaid benefits; or the growing number of retired U.S. citizens living in Mexico, who lack easy access to Medicare-supported services. This article reviews two promising binational initiatives that could help address these challenges-Salud Migrante and Medicare in Mexico; discusses their prospective applications within the context of U.S. health care reform; and identifies potential challenges to their implementation (legal, political, and regulatory), as well as the possible benefits, including coverage of uninsured Mexican immigrants, and their integration into the U.S. health care system (through Salud Migrante), and access to lower-cost Medicare-supported health care for U.S. retirees in Mexico (Medicare in Mexico).

Aunque la reforma del sector sanitario de los Estados Unidos muy probablemente reducirá el número global de ciudadanos estadounidenses de origen mexicano sin cobertura de atención de la salud, esta reforma no afronta los problemas relacionados con esta cobertura para los inmigrantes mexicanos indocumentados, quienes seguirán sin tener seguro aun tras la aplicación de las medidas de la reforma; para los inmigrantes mexicanos documentados de bajos ingresos que no han cumplido el período de espera de cinco años requerido para recibir las prestaciones de Medicaid; o para el número cada vez mayor de ciudadanos estadounidenses jubilados que viven en México y no pueden acceder con facilidad a los servicios de Medicare. En este artículo se analizan dos iniciativas binacionales prometedoras que podrían ayudar a afrontar estos retos: Salud Migrante y Medicare en México. Se tratan además sus futuras aplicaciones dentro del contexto de la reforma del sector sanitario de los Estados Unidos y se señalan los posibles retos para su ejecución (legales, políticos y reglamentarios), al igual que las posibles prestaciones, como la cobertura de los inmigrantes mexicanos no asegurados y su integración en el sistema de atención de la salud de los Estados Unidos (mediante Salud Migrante), y el acceso a atención de la salud de bajo costo, con el apoyo de Medicare, para los jubilados estadounidenses residentes en México (Medicare en México).

Impact of court rulings on health care coverage: the case of HIV/AIDS in Colombia.

This article addresses an emerging issue in health care systems: the impact of judicial rulings on public policy regarding financing and delivery of health care services, and the attendant tensions, contradictions and questions. In Colombia, HIV/AIDS patients' use of a legal instrument called tutela, or writ of protection, has produced abundant jurisprudence and prompted health authorities to respond with decisions about HIV/AIDS service coverage that do not consider epidemiologic criteria and sustainability, introducing distortions in the health care system with respect to financing, priority-setting and universality.

After Chile's health reform: increase in coverage and access, decline in hospitalization and death rates.

In 2005 the government of Chile passed comprehensive health reform. The law mandated coverage by public and private health insurers for selected medical interventions related to fifty-six priority diseases and conditions. This paper presents previously unpublished evidence on various consequences of the reform. It also presents a first, partial evaluation of the reform's impact on access to care, treatment outcomes, hospitalization rates, and medical leave rates for six chronic diseases. For some of those diseases, such as hypertension, types 1 and 2 diabetes, and depression, we find that the reform was linked to growing access to services and increased coverage. For those diseases and for childhood epilepsy and HIV/AIDS, the hospital case-fatality rate dropped.

Mala praxis: la visión de un cirujano / Medical malpractise: a surgeons vision

In this article the author presents a surgeons vision of medical malpractice.

Mala praxis: la visión de un cirujano / Medical malpractise: a surgeon's vision

In this article the author presents a surgeon's vision of medical malpractice.

Realization of the international human right to health in an economically integrated North America.

With the North American Free Trade Agreement (NAFTA), the health care sectors of the United States, Canada, and Mexico are becoming more economically integrated. NAFTA poses major challenges to the realization of the international human right. These include: (1) Cross Border Trade in Medical Products, (2) Cross Border Trade in Medical Services, and the attendant investment protections, (3) Portability and Comparability of Health Insurance Coverage, and (4) Protection of Public Health Insurance Programs. The United States, Mexico, and Canada all provide public health insurance programs either to the entire population as in Canada or to vulnerable groups as in the United States. In none of these countries have private, for-profit providers and insurers been able to provide universal and affordable health coverage and care in a truly free market. Private insurers and for-profit providers should not profit from the care of the healthy and wealthy in ways that compromise the public programs that serve the poor and seriously ill. Nor should they be allowed to use NAFTA processes to compromise public programs. Policy makers must consider implications of NAFTA and move toward assuring access to affordable health care for all people on the North American continent.

A regulamentação do setor de saúde suplementar no Brasil: a reconstrução de uma história de disputas / Government regulation of the private health care market in Brazil: a history of disputes

O artigo reconstrói a disputa travada entre os principais atores sociais interessados diretamente no processo de regulamentação da saúde suplementar no Brasil, no período imediatamente anterior à edição da Lei n°. 9.656/98, destacando convergências e divergências destes atores em relação a 28 temas centrais para a configuração do arcabouço regulatório vigente no Brasil desde 1998. O material utilizado para a descrição e sistematização das posições em disputa no processo regulatório resultou de um estudo empírico, descritivo, de natureza comparativo-contrastante, baseado em análise documental e entrevistas com atores-chave. O estudo sistematiza os principais pontos de polêmica e/ou consenso entre os vários atores, destacando, em particular, as muitas convergências das propostas das entidades médicas com aquelas defendidas pelas organizações de usuários e pelos institutos de defesa dos consumidores, apontando para a possibilidade de construção de um bloco ético-político compromissado com a defesa de uma melhor qualificação da assistência, em contraposição a uma lógica meramente de mercado.

This paper reconstructs the dispute between the main social actors with direct interests in the regulation of private health care in Brazil during the period immediately prior to the passage of Act 9.656/98, highlighting the divergences between these actors in relation to 28 central topics for shaping the regulatory framework prevailing in the country since 1998. The material used in the description and systematization of the positions in the regulatory dispute resulted from an empirical, descriptive, comparative study based on document analysis and interviews with key actors. The study systematizes the main points of controversy and consensus among the various actors, particularly highlighting the many points of agreement between proposals by medical organizations and those of users' organizations and consumer defense institutes, thereby suggesting the possibility of establishing an ethical and political bloc committed to the defense of improved health care as opposed to sheer market logic.

[Government regulation of the private health care market in Brazil: a history of disputes]. / A regulamentação do setor de saúde suplementar no Brasil: a reconstrução de uma história de disputas.

This paper reconstructs the dispute between the main social actors with direct interests in the regulation of private health care in Brazil during the period immediately prior to the passage of Act 9.656/98, highlighting the divergences between these actors in relation to 28 central topics for shaping the regulatory framework prevailing in the country since 1998. The material used in the description and systematization of the positions in the regulatory dispute resulted from an empirical, descriptive, comparative study based on document analysis and interviews with key actors. The study systematizes the main points of controversy and consensus among the various actors, particularly highlighting the many points of agreement between proposals by medical organizations and those of users' organizations and consumer defense institutes, thereby suggesting the possibility of establishing an ethical and political bloc committed to the defense of improved health care as opposed to sheer market logic.

Aseguramiento y cobertura: dos temas criticos en las reformas del sector de la salud / Health insurance and health coverage: two critical issues within the context of health sector reform

The goal of health for all in the year 2000, which was established at Alma Ata more than two decades ago, has led countries in Latin America and the Caribbean to adopt health sector reforms aimed at extending health coverage to each and every individual citizen. Whereas much has come about as a result of reform policies in the way of theory and legislation, in practice the goals that were established are far from attained, and many countries show large gaps in theoretical coverage on the one hand, and true coverage on the other. This is largely due to organizational features and other "endogenous" characteristics of the various countries' health systems, as well as to "exogenous" factors in the political, macroeconomic, social, epidemiologic, and cultural spheres. This document takes a closer look at the different types of health systems that are currently operating in countries of the Region and their impact on sources of health insurance and health coverage for individuals living in those countries. The end of the article focuses on the different strategies adopted by the countries in an effort to extend health coverage, which in some cases involve policies targeting the most vulnerable social groups (AU)

Sistema Hospitalar / Hospital system

O objetivo desta análise é traçar, ao longo de 4 volumes, o perfil do setor hospitalar brasileiro, nos seguintes aspectos: histórico, forma de organizaçäo, relaçäo com os diversos setores e segmentos da economia (equipamentos, convênios médicos, mäo-de-obra, etc.) e aspectos legais relevantes. Neste Volume IV, säo abordados os seguintes pontos: - principais normas legais que regem o setor; - relaçäo de hospitais, por estado e município, com programas de investimentos aprovados, até outubro de 1998, pelo Ministério da Saúde, com recursos do Banco Mundial e BID; - cadastro dos principais fornecedores para o setor hospitalar