Ensuring equitable access to public health care: Two steps forward,one step back

Advancements by the federal government to extend access to health care to Medicaid eligible populations have been countered by state government efforts to curtail program benefits and eligibility. Fiscally and philosophically-based legislation and Medicaid waivers have created a patchwork of state policies that contradict the original civil rights orientation of the program. This examination of equitable access to Medicaid programs and services reviews individual and community factors and fiscal and institutional barriers that contribute to discriminatory practices and then explores ways in which the Patient Protection and Affordable Care Act (ACA) addresses those issues. We find that the ACA funding authorizations for numerous innovative programs strives to substantially redress issues of discriminatory and inequitable service provision.     

Developing and delivering new medical technologies: issues beyond access

The articles in this issue illuminate psychosocial issues raised by the development and delivery of new medical technologies. Five kinds of questions surface repeatedly: questions about a technology's purpose(s), the value judgments it presumes, the locus of its control, the external forces that drive it, and its long-term social risks. These questions take the discussion of new technologies beyond the challenge of improving access to their benefits. They also raise issues that will become increasingly important as the capabilities of medical technology expand. For example, they suggest research questions for three other emerging medical technologies: use of biosynthetic growth hormone to treat short stature in hormonally normal children, genetic tests on fetal cells from the circulating maternal blood, and development of clinically reliable biomarkers of the aging process. Part Three of this issue provides a theoretical basis for encouraging psychosocial perspectives in this area, by illustrating the central role that "robust," multifaceted analysis has come to play within the methods of bioethics.     

Genetic screening technology: ethical issues in access to tests by employers and health insurance committees

Whereas the introduction of new technologies previously has raised the ethical question of who ought to have access to a new procedure or device, genetic testing technology raises the new ethical question of to whom access to a new technology ought to be limited. In this article we discuss the implications of employers and private health insurance companies having access to genetic testing technology. Although there may be legitimate business interests in allowing employers and insurers to conduct genetic screening, there are other valid societal interests in regulating or limiting the use of this technology by third parties. Public policy developed in the area of new genetic technology must reflect such interests.     

Governance,credit access and clean cooking technologies in Sub-Saharan Africa: Implications for energy transition

There is a global effort toward reducing or eliminating dirty fuels and technologies for cooking due to their severe health, environmental and economic implications. Reducing dirty energy usage requires an effective transition toward clean fuels and technologies for cooking. Effective governance and financial systems are needed to hasten the transition toward clean fuels and technologies for cooking. However, not much is known empirically about the role of access to credit and governance in the transition towards clean cooking technologies, especially in sub-Saharan Africa (SSA). This study, therefore, utilizes the two-step-dynamic system generalized method of moment estimator to investigate the effect of access to credit and governance on the adoption of clean cooking technologies in SSA. The findings indicate that access to credit and governance variables do not facilitate clean cooking technologies usage. The conditional analysis also reveals that the governance variables moderate the effect of access to credit to impede the adoption of clean fuels and technologies for cooking. The findings indicate that economic growth, education, and rural population drive the adoption of clean cooking technologies. Sensitivity checks show that the effect of access to credit and governance on clean fuels and cooking technologies usage differs among income and regional groups within SSA. We, therefore, argue that better financial and governance systems are required to hasten the transition toward clean fuels and technologies for cooking in SSA.     

The health care system of the People's Republic of China: Between privatization and public health care

Chinese health care policy has undergone numerous reforms in recent years that have often led to new challenges, inciting the need for further reform. The most recent reforms attempt to find a middle path between public health care provision and commercial private insurance. In this way, China is following in the footsteps of countries that initially increased the role of privatization in the 1990s and at the beginning of the 21st century, but are now gearing towards public health care. However, this process of constant reform has led to a lack of transparency in the functioning of the health care system, provoking a loss in public trust. There remains an important degree of uncertainty about the future direction of developments in China. Nonetheless, a dual financing approach to health care using tax finance and social insurance might yet crystallize, offering a potential model to inform developments in other countries.     

Resettlement challenges faced by refugee claimant families in Montreal: lack of access to child care

Adult refugee claimants experience several well‐documented post‐migratory challenges. Little is known about the resettlement process for refugee claimant families with children. This study reports on 75 open‐ended, in‐depth interviews with refugee claimant families in Montreal about their resettlement challenges and their proposed solutions to them. These interviews were conducted with 33 dyads and triads of children and parents attending a paediatric hospital. Experiences accessing formal and informal child care in Montreal were addressed. Subsequently, a comparative policy analysis was conducted on residency eligibility criteria for child care subsidization. Twenty‐eight out of 39 parents (73%) report a lack of informal or formal child care and 15 out of 33 families (39%) propose improving access to formal child care services. They describe a lack of informal child care as a result of reduced social networks, and affordability as a barrier to formal child care services. Refugee claimants are not eligible for subsidized child care in Quebec. A comparative policy analysis within Canada and comparable countries reveals that this situation is not unique to Quebec. However, most provinces and European countries offer child care subsidies to refugee claimants. Refugee claimants should qualify for child care subsidies. Social workers and community organizations should consider their clients' child care needs in designing programmes and services.     

The effects of sociocultural factors on older Asian Americans' access to care

Most Asian American elders are immigrants to the United States, and sociocultural factors such as English proficiency and immigration status are prominent factors in their lives. Using data from the California Health Interview Surveys to focus on Asian Americans over age 50, this study seeks to identify interethnic differences, and the effects of English proficiency and immigration status in the way older Asian Americans access healthcare. The results indicated that Asian ethnicity, English proficiency, and immigration status have significant independent effects on older Asian Americans' access to care. Implications for social work's role in addressing access disparities are discussed.     

Improving health care delivery to aging adults with disabilities: social work with dual eligibles in a climate of health care reform

Adults aging with disabilities comprise a diverse group. In this article, we identify the prevalence and characteristics of this target population, focusing on adults who are dually eligible for Medicare and Medicaid. We articulate challenges in the delivery of health, social, and support services to adults aging with disabilities, particularly how existing health care policy and financing contributes to fragmentation of care. Finally, we identify opportunities for social workers to advocate for and promote system improvements in the delivery of care for aging adults with disabilities in the current climate of health care reform.     

Health care in post-crisis South Europe: Inequalities in access and reform trajectories

The European debt crisis stimulated debate about the future of national health systems. The objective of this article is to contribute to this debate by examining any changes in the scope and content of universal coverage and underlying pattern of solidarity in South Europe. Access to health care provides the vantage point for our analysis. Inequalities in access are scrutinized along a number of dimensions by using data from various sources. Our main conclusions clearly show that the public health care systems in Italy and, particularly, in Spain weathered the crisis pretty well and retained their universalistic features. Nonetheless, rising supplemental private coverage (of an “occupational-mutualist” type) adversely impacts access, but it is unclear how this will unfold in the near future. Tackling fragmentation through expansion and equalization of coverage, though for a comparatively “lean” basket of provisions, has been the focus of reforms in Portugal and Greece. This keeps private spending high and sustains inequalities, whereas any prospects for a stronger variant of universalism remain an open question.     

Attitudes to prioritization in selected health care activities

The aim of this study was to measure attitudes to health care prioritization in various Finnish population groups. Three study groups were established: 1) the general public (n=4260); 2) politicians (n=1427); and 3) medical and social work professionals (n=1055).
The following background data were obtained: sex, year of birth, marital status, number of children, education, profession, personal income, self-perceived health, and how subjects viewed their own future and whether they were satisfied with their lives. Information on activities involving prioritization of health service was elicited by presenting a list of 16 health care activities. Respondents evaluated these activities as 1) more important than average, 2) of average importance, or 3) less important than average (indicated as numbers 1-3).
The response rate was 59.3%, and 57.2% (n=3858) of the original sample was accepted for analysis. The politicians and profes-sionals showed almost identical attitudes. All groups prioritized treatment of life-threatening diseases among children. The general public prioritized high-tech surgery more highly than professionals or politicians. Alternative medicine and cosmetic surgery were the two least important activities. All groups agreed about prioritization of serious diseases among children, care of dying patients, prevention, surgery which helps people to perform their everyday tasks, and home care for the disabled elderly. Professionals and politicians prioritized mental health more highly than the population. The general public prioritized intensive care for premature babies with a low birth weight (less than 800 g). Professionals prioritized family planning more highly than politicians and the population. The results resemble those obtained in Britain, indicating that attitudes towards priorities in health are similar between Britain and Finland, and that the respondents' professions determine attitudes more strongly than does cultural background.     

Early access and use of housing: care leavers and other young people in difficulty

This paper presents findings from a study of how care leavers access and use housing services, and what they said had helped them to do so. The sample comprised 80 care leavers, and, for comparison, a group of 59 young people (termed ‘in difficulty’) who met certain criteria of disadvantage. Care leavers were found to have fewer crisis transitions and less experience of homelessness, together with a much higher level of autonomy and support in their first accommodation, relative to other young people in difficulty. Several factors are identified that, from the care leavers' point of view, contributed to their better access and use of housing services, including having family and friends to turn to, and leaving care teams that negotiated on their behalf with housing services. The paper concludes that care leavers had more positive housing experiences than other young people in difficulty, helped by the improved preparation for independence and ongoing support available to them from leaving care teams.     

Facing Up to Underfunding: Equity and Retrenchment in Community Care

Local social services departments in the UK are expected to distribute their cash-limited budgets for community care in ways that achieve an equitable allocation of resources in situations where, with present levels of funding, they cannot meet all the needs with which they are presented. This paper discusses a case study of the introduction of a needs-based formula to allocate a local authority's budget for home care services and a follow-up survey to investigate whether services reached the people intended to benefit. The article argues that the gatekeeping role of community care assessments is important to safeguard equity without the inflexibility of highly standardized tests of eligibility. However, with the new Labour government seeking to reduce dependency on public expenditure, and a growing lobby for national standards of social care, it will be increasingly important that local authorities justifiy their different practices with evidence about how they relate to local needs.     

Young people leaving care: health, well-being and outcomes

This paper focuses on the health and well‐being of young people making the transition from care to independent adulthood. It draws on findings from a wider study of outcomes for young people leaving care in England. Notably, the study used, as its key outcome indicators, measures of general and mental well‐being. In doing so, it was able to explore the interrelationship between these areas and young people's overall progress after care. The paper explores the extent to which young people experience difficulties related to physical and mental health, disability and emotional and behavioural problems. It will show that such difficulties can impact upon and be influenced by overall well‐being and post‐care progress in more traditional outcome areas such accommodation and career, and will suggest that the transition from care itself can adversely affect health and well‐being. The paper considers these issues within the context of a changing policy framework which has given increased priority to the health and well‐being of young people in and leaving care, particularly in light of the Children (Leaving Care) Act 2000. It considers the ways that young people are supported to address health and well‐being and the implications for and impact on leaving care services.     

The impact of ethnicity on attitudes toward health care reform in New Mexico

Latinos tend to have significantly lower levels of access to general and top quality medical care than do non-Latino whites, and although disparities in access to health care have diminished for all other minority groups over time, they have widened for Latinos. Given these trends, current attempts to provide universal health care at both the national and state levels across the United States have large implications for the health status of Latinos. The objective of this analysis is to determine whether Latinos have different attitudes regarding health reform than non-Latino whites. Our data are from a statewide random digit dialing telephone survey of New Mexico residents, age 18 and older, conducted in the Fall of 2007. With a Latino population of 44% and ongoing health care reform efforts by the state legislature, New Mexico is an ideal location for this analysis. After controlling for a host of individual level factors, our findings suggest that while Latinos are less likely to identify health care as a salient state issue relative to the economy and crime, they are more likely than non-Latino whites to believe affordable health care programs are important. Finally, Latinos view employers, more than government or individuals, to be responsible for expanding health care coverage.     

Public health care in the balance: exploring popular support for health care systems in the European Union

Which factors explain intra‐ and inter‐country variations in levels of public support for national health care systems within the European Union, and why? We propose that public opinion towards public health care is dependent on (1) the type of welfare state regime to which the various European welfare states belong, (2) typical features of the national care system and (3) individual social and demographic characteristics, which are related to self‐interest or morality oriented motives. To assess the explanatory power of these factors, data from the Eurobarometer survey series are analysed. Support for public health care appears to be particularly positively related to social‐democratic attributes of welfare states, whereas support drops with increasing degrees of liberalism and conservatism. Further, support for public health care proves to be associated with wider coverage and public funding of national care services. We also find higher levels of support in countries with scarce social services for children and the elderly, and larger proportions of female (part‐time) employment. Lastly, with respect to individual characteristics, we find remarkably little evidence for self‐interest oriented motives affecting the preference for solidary health care arrangements.     

Probability perceptions and preventive health care

We study the effect of perceptions in comparison with more objective measures of risk on individuals’ decisions to decline or accept risk reducing interventions such as flu shots, mammograms, and aspirin for the prevention of heart disease. In particular, we elicit individuals’ subjective probabilities of risk, with and without the interventions, and compare these perceptions to individually predicted risk based on epidemiological models. Respondents, especially women, appear to be aware of some of the qualitative relationships between risk factors and probabilities. However, on average they have very poor perceptions of the absolute probability levels as reported in the epidemiological literature. Perceptions of the level of risk are less accurate if a respondent is female and has poor numeracy skills. We find that perceived probabilities significantly affect the subsequent take-up rate of flu shots, mammograms, and aspirin, even after controlling for individually predicted risk using epidemiological models.     

Relationship between childbirth and access to postsecondary education among young women ageing out of foster care

Early childbirth is common among young women ageing out of foster care and may impede their educational progress. However, few studies have explored access to postsecondary education among young mothers who have been in foster care. The present study used data from a large, national sample of young people in foster care (National Youth in Transition Database, NYTD) to examine the link between early childbirth and young women's access to postsecondary education between ages 19 and 21, controlling for an array of covariates. The study sample included 2,207 young women who had completed a high school diploma or GED by age 19 and who participated in three NYTD interviews at ages 17, 19 and 21. Childbirth between ages 19 and 21 was linked to decreased access to postsecondary education. However, no relationship was found between access to postsecondary education and childbirth by age 17 or childbirth between ages 17 and 19. Implications for policy, practice and research are discussed.     

Early feeding problems: identification by parents and health care personnel

This study investigated the discrepancy between parental reports indicating a high prevalence of feeding problems during infancy and the relatively low identification rate of such cases at child health care centers. Thirty nurses were interviewed about definitions, prevalence, causes, and interventions for such problems. Thereafter, they were retrospectively asked about presence of feeding problems in 30 infants, for whom parents had reported existence of feeding problems, and in 30 control infants. A group ( n =22) based on parent-nurse agreement about the existence of a problem was compared with a group ( n = 8) identified as problematic by parents only and with the control group. The parent-nurse agreement group stood out as more burdened: infant growth was affected, there had been feeding history problems (breastfeeding, weaning and protracted meals) and the level of parental concern was higher. More infant respiratory infections were reported, and more medication had been prescribed for this group. Although nurses seemed to rely to a great extent on parental reports in identifying feeding problems, the present results suggested that the parent-nurse discrepancy in identification rate may occur due to nurses' weighting of parental complaints with other factors such as the child's general condition and the family social situation.