Single-Payer National Health Insurance: Physicians\u27 Views

Background Forty-one million Americans have no health insurance and, despite the growth of managed care, medical costs are again increasing rapidly. One proposed solution is a single-payer health care financing system with universal coverage. Yet, physicians\u27 views of such a system have not been well studied. Methods We surveyed a random sample of physicians (from the American Medical Association Masterfile) in Massachusetts, regarding their views on a single-payer health care financing system and other financing and physician work-life issues that such a system might affect. Results Of 1787 physicians, 904 (50.6%) responded to our survey. When asked which structure would provide the best care for the most people for a fixed amount of money, 63.5% of physicians chose a single-payer system; 10. 7%, managed care; and 25.8%, a fee-for-service system. Only 51.9% believed that most physician colleagues would support a single-payer system. Most respondents would give up income to reduce paperwork, agree that it is government\u27s responsibility to ensure the provision of medical care, believe that insurance firms should not play a major role in health care delivery, and would prefer to work under a salary system. Conclusions Most physicians in Massachusetts, a state with a high managed care penetration, believe that single-payer financing of health care with universal coverage would provide the best care for the most people, compared with a managed care or fee-for-service system. Physicians\u27 advocacy of single-payer national health insurance could catalyze a renewed push for its adoption

COVID-19 in Prisons and Jails in the United States

In mid-March 2020, the first case of novel coronavirus 2019 (COVID-19) was diagnosed at Riker’s Island, the main jail complex in New York City. Within 2 weeks,more than 200 cases were diagnosed within the facility, despite efforts to curb the spread.The situation at the Cook County jail in Chicago is similar, with about 350 incarcerated persons and staff members testing positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus as of early April 2020. Many other jails and prisons have reported outbreaks of COVID-19 and related deaths. Prior viral epidemics have wrought havoc in carceral settings. An account from San Quentin prison detailing the Spanish influenza of 1918 estimated that half of the 1900 inmates contracted the disease during the first wave of the epidemic; sick calls increased from 150 to 700 daily. Contrary to protocol, most of the ill were kept in the general prison population because the hospital ward was full. At present, jails (which house individuals awaiting trial or serving short sentences) and prisons (which house individuals who have been convicted of crimes and are serving longer sentences) are usually crowded. When they are unable to adhere to measures needed to contain and mitigate a viral epidemic, incarcerated persons, staff, and the wider community are endangered

The effect of Massachusetts health reform on 30 day hospital readmissions: retrospective analysis of hospital episode statistics

Objectives: To analyse changes in overall readmission rates and disparities in such rates, among patients aged 18-64 (those most likely to have been affected by reform), using all payer inpatient discharge databases (hospital episode statistics) from Massachusetts and two control states (New York and New Jersey). Design: Difference in differences analysis to identify the post-reform change, adjusted for secular changes unrelated to reform. Setting: US hospitals in Massachusetts, New York, and New Jersey. Participants: Adults aged 18-64 admitted for any cause, excluding obstetrical. Main outcome measure Readmissions at 30 days after an index admission. Results: After adjustment for known confounders, including age, sex, comorbidity, hospital ownership, teaching hospital status, and nurse to census ratio, the odds of all cause readmission in Massachusetts was slightly increased compared with control states post-reform (odds ratio 1.02, 95% confidence interval 1.01 to 1.04, P<0.05). Racial and ethnic disparities in all cause readmission rates did not change in Massachusetts compared with control states. In analyses limited to Massachusetts only, there were minimal overall differences in changes in readmission rates between counties with differing baseline uninsurance rates, but black people in counties with the highest uninsurance rates had decreased odds of readmission (0.91, 0.84 to 1.00) compared with black people in counties with lower uninsurance rates. Similarly, white people in counties with the highest uninsurance rates had decreased odds of readmission (0.96, 0.94 to 0.99) compared with white people in counties with lower uninsurance rates. Conclusions: In the United States, and in Massachusetts in particular, extending health insurance coverage alone seems insufficient to improve readmission rates. Additional efforts are needed to reduce hospital readmissions and disparities in this outcome

Disparities in pulmonary fibrosis care in the United States: an analysis from the Nationwide Inpatient Sample

Background: Idiopathic pulmonary fibrosis is a disease with high morbidity and mortality. Care for these patients, including lung transplantation, may provide significant benefits, but is resource-intensive and expensive. Disadvantaged patients with IPF may hence be at risk for receiving inferior care. Methods: We analyzed data from the Nationwide Inpatient Sample, a database consisting of all hospitalizations from a 20% sample of US hospitals. We identified adults hospitalized with IPF between 1998 and 2011 using ICD-9 codes. We assessed the effect of insurance coverage and socioeconomic status (SES) on lung transplantation, a treatment that may improve survival. We also examined the effect of coverage and SES on mortality, as well as discharge to inpatient rehabilitation and receipt of a lung biopsy, two markers of the intensity of care delivered. We used multiple logistic regression to adjust for patient and hospital characteristics. Results: We identified 148,877 hospitalizations that met our definition of pulmonary fibrosis. In the main adjusted analyses, hospitalizations of patients with Medicaid (OR 0.30, 95% CI 0.16–0.57) or no insurance (OR 0.22, 95% CI 0. 07–0.72) were less likely to result in a lung transplantation compared to hospitalizations of those with non-Medicaid insurance. Those of lower SES were also less likely to undergo transplantation, while hospitalized patients with Medicaid and the uninsured were less likely to be discharged to inpatient rehabilitation or to receive a lung biopsy. Conclusions: Among hospitalized patients with IPF, those with lower SES, Medicaid coverage and without insurance were less likely to receive several clinical interventions

Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients

Introduction: The Affordable Care Act (ACA) and the 2006 Massachusetts (MA) health reform law, on which the ACA was based, aimed to improve the affordability of care largely by expanding publicly sponsored insurances. Both laws also aimed to promote consumer understanding of how to acquire, maintain and use these public plans. A prior study found an association between the level of cost-sharing required in these plans and the affordability of care. Preparatory to a quantitative study we conducted this qualitative study that aimed to examine (1) whether cost sharing levels built into the public insurance types that formed the backbone of the MA health reform led to unaffordability of care and if so, (2) how insurances with higher cost sharing levels led to unaffordability of care in this context. Methods: We interviewed 12 consumers obtaining the most commonly obtained insurances under MA health reform (Medicaid and Commonwealth Care) at a safety net hospital emergency department. We purposefully interviewed a stratified sample of higher and low cost sharing recipients. We used a combination of inductive and deductive codes to analyze the data according to degree of cost-sharing required by different insurance types. Results: We found that higher cost sharing plans led to unaffordability of care, as evidenced by unmet medical needs, difficulty affording basic non-medical needs due to expenditures on medical care, and reliance on non-insurance resources to pay for care. Participants described two principal mechanisms by which higher cost sharing led to unaffordability of care: (1) cost sharing above what their incomes allowed and (2) poor understanding of how to effectively acquire, maintain and utilize insurance new public plans. Conclusions: Further efforts to investigate the relationship between perceived affordability of care and understanding of insurance for the insurance types obtained under MA health reform may be warranted. A potential focus for further work may be quantitative investigation of how the level of calibration of cost-sharing to income and understanding of insurances under the MA reform was associated with perceived affordability of care. Electronic supplementary material The online version of this article (doi:10.1186/s12939-015-0240-5) contains supplementary material, which is available to authorized users

Effects Of The ACA’s Health Insurance Marketplaces On The Previously Uninsured: A Quasi-Experimental Analysis

Descriptive studies have suggested that the Affordable Care Act’s (ACA) health insurance Marketplaces improved access to care. However, no quasi-experimental evidence is currently available to support these findings. We use longitudinal survey data to compare previously- uninsured adults to adults who had employer-sponsored insurance (ESI) prior to the ACA, in the income range eligible for subsidized Marketplace coverage (138-400% of poverty). Among the previously-uninsured group, the ACA led to a significant decline in the uninsurance rate (-10.8 percentage points), decreased barriers to medical care, increased use of outpatient services and prescriptions drugs, and increased identification of high blood pressure, compared to a control group with stable ESI. Changes were largest among those with incomes between 138-250% of poverty, who were eligible for the ACA’s cost-sharing reductions. Our quasi-experimental approach provides rigorous new evidence that the ACA’s Marketplaces led to improvements in several important health care outcomes, particularly among lower-income adults

Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics

Objectives To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. Design Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. Setting Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. Participants Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). Main outcome measures Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. Results After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval −1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (−1.9%, −8.5% to 5.1%) or white and Hispanic people (2.0%, −7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, −2.3% to 5.3%). Conclusions Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions

Biological conversion assay using Clostridium phytofermentans to estimate plant feedstock quality

BACKGROUND: There is currently considerable interest in developing renewable sources of energy. One strategy is the biological conversion of plant biomass to liquid transportation fuel. Several technical hurdles impinge upon the economic feasibility of this strategy, including the development of energy crops amenable to facile deconstruction. Reliable assays to characterize feedstock quality are needed to measure the effects of pre-treatment and processing and of the plant and microbial genetic diversity that influence bioconversion efficiency. RESULTS: We used the anaerobic bacterium Clostridium phytofermentans to develop a robust assay for biomass digestibility and conversion to biofuels. The assay utilizes the ability of the microbe to convert biomass directly into ethanol with little or no pre-treatment. Plant samples were added to an anaerobic minimal medium and inoculated with C. phytofermentans, incubated for 3 days, after which the culture supernatant was analyzed for ethanol concentration. The assay detected significant differences in the supernatant ethanol from wildtype sorghum compared with brown midrib sorghum mutants previously shown to be highly digestible. Compositional analysis of the biomass before and after inoculation suggested that differences in xylan metabolism were partly responsible for the differences in ethanol yields. Additionally, we characterized the natural genetic variation for conversion efficiency in Brachypodium distachyon and shrub willow (Salix spp.). CONCLUSION: Our results agree with those from previous studies of lignin mutants using enzymatic saccharification-based approaches. However, the use of C. phytofermentans takes into consideration specific organismal interactions, which will be crucial for simultaneous saccharification fermentation or consolidated bioprocessing. The ability to detect such phenotypic variation facilitates the genetic analysis of mechanisms underlying plant feedstock quality

Massachusetts health reform and disparities in joint replacement use: difference in differences study

Objective: To estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly serve poor people (“safety net hospitals”). Design: Quasi-experimental difference in differences study examining change after reform in the share of procedures performed in safety net hospitals by race/ethnicity and area income, with adjustment for patients’ residence, demographics, and comorbidity. Setting: State of Massachusetts, United States. Participants: Massachusetts residents aged 40-64 as the target beneficiaries of reform and similarly aged residents of New Jersey, New York, and Pennsylvania as the comparison (control) population. Main outcomes measures Number of knee and hip replacement procedures per 10 000 population and use of safety net hospitals. Procedure counts from state discharge data for 2.5 years before and after reform, and multivariate difference in differences. Poisson regression was used to adjust for demographics, economic conditions, secular time, and geographic factors to estimate the change in procedure rate associated with health reform by race/ethnicity and area income. Results: Before reform, the number of procedures (/10 000) in Massachusetts was lower among Hispanic people (12.9, P<0.001) than black people (28.1) and white people (30.1). Overall, procedure use increased 22.4% during the 2.5 years after insurance expansion; reform in Massachusetts was associated with a 4.7% increase. The increase associated with reform was significantly higher among Hispanic people (37.9%, P<0.001) and black people (11.4%, P<0.05) than among white people (2.8%). Lower income was not associated with larger increases in procedure use. The share of knee and hip replacement procedures performed in safety net hospitals in Massachusetts decreased by 1.0% from a level of 12.7% before reform. The reduction was larger among Hispanic people (−6.4%, P<0.001) than white people (−1.0%), and among low income residents (−3.9%, p<0.001) than high income residents (0%). Conclusions: Insurance expansion can help reduce disparities by race/ethnicity but not by income in access to elective surgical care and could shift some elective surgical care away from safety net hospitals