Public policy changes and the economics of academic medicine.
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Academic Medical Centers↗
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The distributional effects of national health insurance in Quebec.
In November of 1970 a major change in public health policy occurred in Quebec: the movement from a mixed private-public system to a completely public system of financing health care (known as Medicare). This policy change had important economic effects on the distribution of income, taxation, and health care costs. This paper analyzes these economic effects by focusing on the changes in financial burden of medical care costs between 1969-70 and 1971-72 for eight income classes. The key results that emerge are: the total cost of medical care increases sharply for all of the income groups, and the burden of the cost of medical care becomes more equitable across the income groups. Based on these results, policy considerations for the present debate on national health insurance in the United States are offered.
Financing, Government↗
Factors influencing the consumption of alcohol and tobacco: the use and abuse of economic models.
This paper is concerned with the use of economic models in the debate about the role that tax increases and restrictions on advertising should play in reducing the health problems that arise from the consumption of alcohol and tobacco. It is argued that properly specified demand models that take account of all the important factors that influence consumption are required, otherwise inadequate modelling may lead to misleading estimates of the effects of policy changes. The ability of economics to deal with goods such as alcohol and tobacco that have addictive characteristics receives special attention. Recent advances in economic theory, estimation techniques and statistical testing are discussed, as is the problem of identifying policy recommendations from empirical results.
Alcoholism↗
Is the Canadian health care system more effective at expenditure control than previously thought? A reply to Peter Coyte.
In an article published by the Journal of Public Health Policy (Summer 1990), Peter C. Coyte argues that it is not empirically valid to say that the introduction of universal medical insurance in Canada successfully contained the growth in the share of society's resources devoted to the health care industry. During the period under consideration, both Canada and the United States witnessed several major policy changes in the provision and regulation of health services. Coyte's decision to apply a simple time trend to the data assumes away these changes, especially the introduction of universal medical insurance in Canada in 1971, whose influence on health expenditures is itself the primary subject of inquiry of this paper. We conclude that both the unadjusted and the adjusted data suggest that the Canadian universal health system has been a resounding success economically, once the appropriate periodization is applied to the data, reflecting the institutional and policy changes that took place. Finally, we propose suggestions for future research with respect to measuring resource usage in the Canadian and U.S. health care systems.
Canada↗
Fertility intentions and subsequent behavior: a longitudinal study in rural India.
This report compares fertility and family planning intentions of rural Indian women in 1975 with actual outcomes in 1987. Ninety-four of 103 respondents who had fewer children than they wanted in 1975 and had stated definite intentions with respect to future fertility and contraceptive use were reinterviewed in 1987. Overall, women had fewer children than desired and stopped childbearing when they reached or closely approximated their ideal number of sons. Since sons were clearly the determinant of "reproductive success," it is argued that only a significant change in the status of rural women can bring about widespread compliance with the official family planning program's two-child norm.
Adolescent↗
Legalizing drugs: lessons from (and about) economics.
Although applications of cost-benefit analysis (CBA) to the problem of drug policy are few in number and relatively primitive, they illustrate both the potential and limitations of CBA to produce critical insights that might improve drug policy making. But even the ideal CBA of drug policy could never produce a definitive conclusion about the desirability of drug legalization. Another tool of economics, analysis of price elasticity of demand, holds the potential to generate understanding of the likely effects of policy changes in the monetary and psychological prices associated with policy reforms.
Cost-Benefit Analysis↗
Health policy and the emerging tobacco reality.
Public policy is part of and a creator of modern environments. By intent or neglect, it affects our socially-created and natural worlds. It sets the odds for what organizations and individuals are likely to produce and consume in the form of goods, services and information, and assures how equitably these options for choice-making--and thus for life styles--are dispersed among social and economic groups. Policy is also created by environments: it is influenced by the reality of changing conditions and by the perceptions of those changes by groups who are organized to influence policymakers' views of 'reality'. The direction, humaneness and healthfulness of societal changes--to the extent that they can be guided--depend on whether new and old things are seen by policymakers in new or old ways. Creating environments conducive to health thus requires a two-pronged effort. It means: (1) developing policies that provide incentives to producers and consumers to make more healthful choices than they do today; and (2) creating a social and political climate that will encourage policymakers to choose more healthful policy options. This view point is illustrated here through an analysis of the smoking and health issue, in which changing conditions can potentially be healthfully guided, or alternatively, left to the vagaries of political and economic events. This article outlines the changing economics of tobacco, mainly as seen in its largest form in the U.S.A., its policy implications, and a political strategy to move policy in more healthful directions. Economic data reveal the tobacco sector in affluent nations as one that has been slowly declining, but now at an accelerating rate. At the same time, the tobacco economy is a growing sector in less-industrialized nations. Policy issues involve how to deal with the economic changes in health-promoting ways. Strategically this requires two simultaneous efforts. One is education/informational: posing the smoking/health issue in light of changing conditions, and addressing policy-relevant data (both economic and value-oriented) to the gatekeepers of public action and information (e.g. policymakers and media). The second is environmental/organizational, to improve the feasibility of policy changes by establishing means for transition planning in the tobacco economy.
Cross-Cultural Comparison↗
1984 update on the world economic crisis and the children: a United States case study.
A previously published report by these authors on the impact in the United States of recession on children's health emphasized four points: available monitoring systems are not adequate for reporting on the health of children in a timely fashion; the monitoring of maternal and child health must emphasize data on population subgroups, i.e., minorities, the poor and those hardest hit by recession; the health of poor children is adversely affected and their numbers dramatically increased during the recession of 1981-82; and comparisons between the recession of 1974-75 and that of 1981-82 suggest that expansion of health services and social support systems during the recession of 1974-75 had a cushioning effect that protected the health of children, while the curtailment of many of these programs during the 1981-82 recession is associated with adverse health trends, especially among the most vulnerable population subgroups. Data on these issues are appreciably better now than they were nine months ago, thus further validating the points made above. As with the previous report, officially released current data are abundant for economic indicators (even for early 1984), but are sparse for health status indicators. The previous report also observed that the health status of children is influenced by interdependent and interlocking factors that include economic well-being and access to health services and social supports. A new analysis attempts to unlock those relationships and measure the impact of lost welfare benefits, implemented as a result of the Omnibus Reconciliation Act of 1981 (OBRA), and the separate impact of the serious recession of 1981-82. That analysis shows the poverty rate for children increased by 7.6 percentage points between 1981 and 1982. Approximately 60 percent of the increase is attributable to the recession and 40 percent to social policy changes effected after 1981.
Child↗
The competitive effects of health maintenance organizations: another look at the evidence from Hawaii, Rochester, and Minneapolis/St. Paul.
There has been much discussion about the potential cost-containing impact of HMOs upon the local medical care market. Three areas have been identified by various observers as experiencing such beneficial effects: Hawaii, after the development of Kaiser in the late 1950s; Rochester, New York, which experienced rapid HMO growth and declining Blue Cross hospital use in the late 1970s; and Minneapolis/St. Paul, which has been the focus of vigorous HMO competition in the last decade. While comprehensive data on health care expenditures are not available, bits of evidence can be pieced together to develop case studies of each area. Careful review of the available data often identifies internal inconsistencies and contradictions, but in none of the three sites is there a reduction in hospital use that is most plausibly attributed to HMO competition. Instead, the reported reductions are in each case attributable to other factors--including biases in data, long-term trends predating HMOs, indirect effects of other policy changes, and other forms of competition.
Blue Cross Blue Shield Insurance Plans↗
The age extremes for reproduction: current implications for policy change.
The changing demographic features of births in the United States include an increasing number of older women and a decreasing number of adolescents giving birth. Births in adolescents have lower risks than those in women more than 34 years of age and probably of those more than 30 years of age. There is an increase in complicated pregnancies in the United States, related, no doubt in part, to the above. Older women require more costly, high-technology prenatal care, such as genetic counseling, genetic antenatal diagnosis, amniocentesis, ultrasonography, and electronic fetal heart rate testing. The financing of health care needs to recognize these changes. Detailed studies of the economics of perinatal care, more specific to patient population mix and complication-treatment patterns are needed to establish priorities with the payment system to assure appropriate care.
Adolescent↗
Economic impact of reducing hospitalization for mastectomy patients.
In 1985, two policies designed to reduce hospitalization charges for mastectomy patients were instituted at the M.D. Anderson Cancer Center at Houston. The first was a policy of "same-day" admissions for elective surgery patients, and the second was early postoperative discharge for mastectomy patients with suction catheter drains in place. The economic savings resulting from these policies was analyzed by comparing demographics, operation, stage of disease, hospital stay, hospital charges, and complications for two groups of patients. Fifty-nine consecutive mastectomy patients treated between 1983 and 1984, before these policy changes, had "standard management" consisting of hospital admission 24 hours before surgery and discharge only after the surgical drains were removed. Sixty-one consecutive mastectomy patients treated between 1986 and 1987, after these policy changes went into effect, were admitted from the recovery room after surgery and were discharged with drainage catheters in place, usually within 72 hours. All operations were performed by the same faculty surgeon as a representative experience of the General Surgery faculty. The average hospital stay was reduced from 10.5 to 4.3 days. A mean 39% reduction in hospital charges (from $4867.00 to $2981.00) was achieved by instituting the policies of "same-day" admission and early postoperative discharge with drainage catheters in place. Complication rates were not changed. Implementation of this policy resulted in an estimated savings of $750,000.00 in the hospital care of approximately 400 patients treated at the M.D. Anderson Cancer Center at Houston each year. Adjustments in patient care delivery systems from a predominantly inpatient to an outpatient setting required changes in outpatient nursing responsibilities (although not in new personnel). Patient education and written instructions for home care of surgical wounds and drainage catheters were essential for implementing an early discharge policy. With these facts in mind, hospital admission on the day of operation and early postoperative discharge with drainage catheters in place should be the goal for most mastectomy patients.
Cancer Care Facilities↗
Purchasing power: business and health policy change in Massachusetts.
As in many states around the country, health care costs in Massachusetts had risen to an unprecedented proportion of the state budget by the early 1980s. State health policymakers realized that dramatic changes were needed in the political process to break provider control over health policy decisions. This paper presents a case study of policy change in Massachusetts between 1982 and 1988. State officials formulated a strategy to mobilize corporate interests, which were already awakening to the problems of high health care costs, as a countervailing power to the political monopoly of provider interests. Once mobilized, business interests became organized politically and even became dominant at times, controlling both the policy agenda and its process. Ultimately, business came to be viewed as a permanent part of the coalitions and commissions that helped formulate state health policy. Although initially allied with provider interests, business eventually forged a stronger alliance with the state, an alliance that has the potential to force structural change in health care politics in Massachusetts for years to come. The paper raises questions about the consequences of such alliances between public and private power for both the content and the process of health policymaking at the state level.
Commerce↗
Restructuring federalism: the impact of Reagan policies on the family planning program.
Through fiscal cutbacks and structural changes, Reagan's federalism assaulted the ethos of public health. In assessing the effects of Reagan policies on a basic public health program, family planning services, we find a substantial decrease in spending for this program, a reduction in the numbers of patients served, and increased variation among the states in the provision of services to low-income women. These effects are comparable with findings from other studies on the impact of Reagan's federalism upon social programs and have manifold implications for public health.
Capital Financing↗
The women's movement and older women's health: issues and policy implications.
Since women are an increasing proportion of the older population, the health issues that affect older Americans must be regarded in large part as women's issues. Women experience aging differently from men. The advantage in life expectancy of women over men is not always a boon. Older women have substantially lower incomes and higher poverty rates, are more likely to be widowed and living alone, and depend more on entitlement and social service programs. This paper traces the evolution of the women's movement and identifies some of the health care problems of older women in terms of psychological, socio-cultural, and economic factors. The role of the medical establishment and federal regulations that affect older women are examined. The White House Conference on Aging (1981) is seen as a prelude to the current policies of the Administration that affect older women. Necessary policy changes on the Federal and local levels are discussed as well as the need for redirection in the women's health movement.
Aged↗
Economic behaviour of heroin users and effects of policy measures.
The object of this study is to describe the behaviour of heroin users from an economic point of view in such a way as to enable tracing the influence of policy measures. In order to describe the heroin users' behaviour, data have been collected regarding relevant variables and relations between variables by interviewing 80 heroin users in the Netherlands. Based on these data a computer model has been developed. The objective of the model is two-fold: 1) Describing the behaviour of a group of heroin users in connection with the process of obtaining money and heroin in order to determine the factors which influence the quantity of heroin bought and consumed. 2) Carrying out some scenario analyses in order to examine the effects policy changes might have on variables such as heroin use and quantity of money obtained illegally.
Computer Simulation↗
How have PPS changes affected allocation of Medicare spending for hospital care? A case study of New York State.
Complex national factors went into the development of key policies of the federal prospective payment system, and the effects of these policies varied in different parts of the country. One state particularly affected by these changes, and for the most part in a positive way, was New York. This paper focuses on the Medicare PPS policy changes and their impact nationally. An analysis of the experience of New York state, which had been under a stringent hospital cost containment system before PPS, provides a laboratory to understand how key federal policies affected different types of hospitals in that state as well as nationally.
Cost Allocation↗
Global politics in Mexico City.
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Abortion, Induced↗
The economic impact of AIDS: a challenge for nursing.
Estimates to determine the cost of financing AIDS care have been uncertain. Current policies governing private insurance as well as Medicaid/Medicare eligibility have created a number of barriers for people with AIDS (PWA). As the number of AIDS cases increase, nursing will play a crucial role in developing necessary policy changes to improve access to care, contain costs, and continue to provide much needed care to PWA.
Acquired Immunodeficiency Syndrome↗