Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Below: Frequency of institutional-level barriers to health care among sex workers in Vancouver, Canada, 2010–2013

Full article at:   http://goo.gl/2p7VoO

By: 

M. Eugenia Socías, Paul Nguyen, Julio Montaner, Kate Shannon 
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada

M. Eugenia Socías, Julio Montaner, Kate Shannon 

Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada

Jean Shoveller 

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

Chili Bean

Sex Workers United Against Violence Society, Vancouver, BC, Canada

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Open Enrollment Timeline for 2016 Marketplace Coverage

Via:  https://goo.gl/Mqc0Yj

Health Insurance Coverage among Women of Reproductive Age Before & After Implementation of the Affordable Care Act

OBJECTIVES:

The Affordable Care Act's expansions to Medicaid and private coverage are of particular importance for women of childbearing age, who have numerous preventive care and reproductive health care needs.

STUDY DESIGN:

We conducted two national surveys, one in 2012 and one in 2015, collecting information about health insurance coverage and access to care from 8000 women aged 18-39. We examine type of insurance and continuity of coverage between time periods, including by poverty status and whether or not women live in a state that expanded Medicaid coverage.

RESULTS:

The proportion of women who were uninsured declined by almost 40% (from 19% to 12%), though several groups, including U.S. born and foreign-born Latinas, experienced no significant declines. Among low-income women in states that expanded Medicaid, the proportion uninsured declined from 38% to 15%, largely due to an increase in Medicaid coverage (from 40% to 62%). Declines in uninsurance in non-expansion states were only marginally significant.

CONCLUSIONS:

Despite substantial improvements in health insurance coverage, significant gaps remain, particularly in states that have not expanded Medicaid and for Latinas.

IMPLICATIONS:

This analysis examines changes in insurance coverage that occurred after the Affordable Care Act was implemented. While coverage has improved for many populations, sizeable gaps in coverage remain for Latinas and women in states that did not expand Medicaid.

Full article at:   http://goo.gl/Zqz3r9

By:  Jones RK1, Sonfield A2.

• 1Guttmacher Institute, 125 Maiden Lane, 7(th) Floor, New York, NY 10038. Electronic address: rjones@guttmacher.org.
• 2Guttmacher Institute, 1301 Connecticut Avenue N.W., Suite 700, Washington, D.C. 20036. Electronic address: asonfield@guttmacher.org.
• Contraception. 2016 Jan 20. pii: S0010-7824(15)30093-7. doi: 10.1016/j.contraception.2016.01.003.  

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Changes in Out-Of-Pocket Costs for Hormonal IUDs After Implementation of the Affordable Care Act: An Analysis of Insurance Benefit Inquiries

BACKGROUND:

The Affordable Care Act (ACA) requires that privately insured women can obtain contraceptive services and supplies without cost sharing. This may substantially affect women who prefer an intrauterine device (IUD), a long-acting reversible contraceptive, because of high upfront costs that they would otherwise face. However, imperfect enforcement of and exceptions to this provision could limit its effect.

STUDY DESIGN:

We analyzed administrative data for 417,221 women whose physicians queried their insurance plans from January 2012 to March 2014 to determine whether each woman had insurance coverage for a hormonal IUD and the extent of that coverage.

RESULTS:

In January 2012, 58% of women would have incurred out-of-pocket costs for an IUD, compared to only 13% of women in March 2014. Differentials by age and region virtually dissolved over the period studied, which suggests that the ACA reduced inequality among insured women.

CONCLUSIONS:

Our findings suggest that the cost of hormonal IUDs fell to US$0 for most insured women following the implementation of the ACA.

IMPLICATIONS:

Financial barriers to one of the most effective methods of contraception fell substantially following the ACA. If more women interested in this method can access it, this may contribute to a decline in unintended pregnancies in the United States.

Below:  Percentage of women who would have had out-of-pocket costs for a hormonal IUD, by month. Note: The lighter line begins in January 2013 because the 2012 data do not contain insertion copayments and deductible applicability.

Below:  In each age group: percentage of women who would have had out-of-pocket costs for a hormonal IUD, by quarter

Below:  In each region: percentage of women would have had out-of-pocket costs for a hormonal IUD, by quarter

Full article at:   http://goo.gl/0ilVW4

By:  Bearak JM1, Finer LB2, Jerman J2, Kavanaugh ML2.

• 1Guttmacher Institute, New York, NY 10038, USA. Electronic address: jbearak@guttmacher.org.
• 2Guttmacher Institute, New York, NY 10038, USA. 
• Contraception. 2016 Feb;93(2):139-44. doi: 10.1016/j.contraception.2015.08.018. Epub 2015 Sep 16.

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The ACA and People with HIV: Video Profiles from the Field

Via:  http://goo.gl/8TE04z

Antiretroviral Therapy for HIV/AIDS in Claims Data from Statutory Health Insurance Funds in Germany

The objective of this study is to determine the number of patients who receive anti-retroviral medicinal products (ARMs) and to assess the frequency of prescriptions depending on age, gender and treatment regimen by evaluating German statutory health insurance data. 

We analysed a number of databases of several million customers of various nationwide statutory sickness funds and extrapolated the results to the overall population of the statutory health insurance. The number of HIV-positive patients with ARMs varied considerably between the statutory sickness funds analysed. 

• The number of patients with HIV diagnosis receiving ARMs that are exclusively approved for HIV increased from about 
• 23,262 in 2008 to 
• 30,200 in 2010. 
• For ARMs labelled for both, HIV and HIV/chronic hepatitis B, indications, we calculated about 34,032 patients for the year 2011. 
• In about 24.2% of the cases with HIV-only and HIV plus HIV/chronic hepatitis B-approved ARMs no HIV-diagnosis was documented. 
• Patients in this group were significantly younger and more often female as compared to patients with documented HIV diagnosis who received prescriptions of ARMs. 
• 16.5% of the patients received treatment within the label for chronic hepatitis B. 
• In 7.7% of the patients ARMs were used off-label for prophylaxis (10.0%), for hepatitis (65.0%) or for unknown reasons (25.0%). 
• Hence, the number of people under ARMs was estimated to be below the 44,000 patients calculated for statutory sickness funds patients on the basis of prescription data in 2011. 
• According to our analysis only 39,000 of those could have a documented HIV diagnosis

Below:  Für die gesetzliche Krankenversicherung adjustiert hochgerechnete Alters- und Geschlechtsverteilung für Patienten mit dokumentierter Diagnose und ARM-Verordnungen. Krankenkassen B im Jahr 2011 

Below:  Verordnungshäufigkeit der ARM in Abhängigkeit von der HIV-Diagnose in Krankenkassendaten B. Anteile eingelöster Verordnungen in 1, in 2-3 oder in allen 4 Quartalen

Full article (in German) at:   http://goo.gl/3dMpBT

By:  Tomeczkowski J¹, Mahlich J², Stoll M³.

¹Janssen-Cilag GmbH, Abteilung Health Economics, Neuss, Deutschland. Electronic address: jtomeczk@its.jnj.com.

²Janssen-Cilag GmbH, Abteilung Health Economics, Neuss, Deutschland; Institut für Volkswirtschaftslehre, Universität Wien, Österreich.

³Klinik für Immunologie und Rheumatologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland.

Z Evid Fortbild Qual Gesundhwes. 2015;109(8):594-604. doi: 10.1016/j.zefq.2014.09.002. Epub 2014 Nov 29.

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Medicaid Expansion Did Not Result In Significant Employment Changes or Job Reductions in 2014

Medicaid expansion undertaken through the Affordable Care Act (ACA) is already producing major changes in insurance coverage and access to care, but its potential impacts on the labor market are also important policy considerations. 

Economic theory suggests that receipt of Medicaid might benefit workers who would no longer be tied to specific jobs to receive health insurance (known as job lock), giving them more flexibility in their choice of employment, or might encourage low-income workers to reduce their hours or stop working if they no longer need employment-based insurance. Evidence on labor changes after previous Medicaid expansions is mixed. 

To view the impact of the ACA on current labor market participation, we analyzed labor-market participation among adults with incomes below 138 percent of the federal poverty level, comparing Medicaid expansion and nonexpansion states and Medicaid-eligible and -ineligible groups, for the pre-ACA period (2005-13) and the first fifteen months of the expansion (January 2014-March 2015). Medicaid expansion did not result in significant changes in employment, job switching, or full- versus part-time status. 

While we cannot exclude the possibility of small changes in these outcomes, our findings rule out the large change found in one influential pre-ACA study; furthermore, they suggest that the Medicaid expansion has had limited impact on labor-market outcomes thus far.

Purchase full article at:   http://goo.gl/UViyzj

By:  Gooptu A1, Moriya AS2, Simon KI3, Sommers BD4.

• 1Angshuman Gooptu is a doctoral student in the School of Public and Environmental Affairs at Indiana University, in Bloomington.
• 2Asako S. Moriya (Asako.Moriya@ahrq.hhs.gov) is a service fellow economist in the Center for Financing, Access and Cost Trends at the Agency for Healthcare Research and Quality, in Rockville, Maryland.
• 3Kosali I. Simon is a professor in the School of Public and Environmental Affairs at Indiana University and a research associate at the National Bureau of Economic Research in Cambridge, Massachusetts.
• 4Benjamin D. Sommers is an assistant professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and in the Department of Medicine at Brigham and Women's Hospital, in Boston, Massachusetts.
• Health Aff (Millwood). 2016 Jan 1;35(1):111-8. doi: 10.1377/hlthaff.2015.0747. 

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Growth in Spending on and Use of Services for Mental and Substance Use Disorders After the Great Recession among Individuals with Private Insurance

OBJECTIVE:

Recessions are associated with increased prevalence of mental and substance use disorders, but their effect on use of behavioral health services is less clear. This study examined changes in spending per enrollee for behavioral health services compared with general medical services among individuals with private insurance following the Great Recession that began in 2007.

METHODS:

The National Survey on Drug Use and Health was used to examine the prevalence of behavioral health conditions among persons with private insurance from 2004 to 2013. Truven Health MarketScan Commercial Claims and Encounters data (2004-2012) were used to calculate use of and spending on treatment of behavioral and general medical conditions before and after the recession among individuals with employer-sponsored private health insurance.

RESULTS:

There was a statistically significant increase in serious psychological distress and episodes of major depression between 2007 and 2010. Between 2004-2009 and 2009-2012, the growth in average annual spending per individual slowed for general medical care (from 6.6% to 3.7%) but accelerated for behavioral health care (from 4.8% to 6.6%). From 2009 to 2012, the percentage of individuals receiving inpatient treatment, outpatient treatment, and prescription drugs for behavioral conditions increased, whereas use of these services for general medical care decreased or remained flat. Out-of-pocket costs increased more slowly for behavioral conditions than for other medical conditions.

CONCLUSIONS:

The recession was associated with increased need for and use of behavioral health services among individuals with private insurance. The Mental Health Parity and Addiction Equity Act may have also played a role in facilitating increasing use of behavioral health services after 2008.

Purchase full article at:   http://goo.gl/ydNMGQ

By:   Mark TL¹, Hodgkin D¹, Levit KR¹, Thomas CP¹.

¹Dr. Mark and Ms. Levit are with the Center for Behavioral Health Services Research, Truven Health Analytics (http://truvenhealth.com/), Washington, D.C. (e-mail: tami.mark@truvenhealth.com ). Dr. Hodgkin is with the Heller School for Social Policy and Management and Dr. Thomas is with the Schneider Institute for Health Policy, Brandeis University, Waltham, Massachusetts.

Psychiatr Serv. 2016 Jan 4:appips201500034.

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Percentage of Uninsured Persons Aged < 65 Years with No Health Insurance Coverage Because of Cost, by Race/Ethnicity, US, 2004 & 2014

Via:  http://ht.ly/VrvDU

We Mapped the Uninsured, You'll Notice a Pattern

Via:  http://ht.ly/UZkKw  By: https://twitter.com/nytimes

Health Insurance Coverage & Healthcare Utilization among Infants of Mothers in the National Methadone Maintenance Treatment Program in Taiwan

Children of heroin-using women have a higher risk of unfavorable health and developmental outcomes. Although methadone maintenance treatment (MMT) has been widely used to treat heroin-using pregnant women, potential effects on accessibility and utilization of healthcare service for their offspring are less explored.

We used four national registry and health insurance datasets in Taiwan from 2004 to 2009 to form a population-based matched retrospective cohort study. A total of 1056 neonates born to women in the MMT program (857 born before mother's enrollment in the MMT program [BM], 199 born after mother's enrollment in the MMT program [AM]) was established; 10547 matched non-drug [ND] exposed neonates were identified for comparison. Outcome variables included offspring's health insurance coverage and utilization of preventive, outpatient, and emergency room cares in the first year after birth.

Infants born to mothers on MMT were more likely to have no or incomplete insurance coverage as compared with the socioeconomic status-matched ND group. The BM infants appeared to have fewer preventive care visits, whereas the AM infants utilized outpatient and emergency room services more frequently.

Addiction treatment and harm reduction programs for women of childbearing ages should be delivered in the coordinated framework that ensures comprehensiveness and continuity in healthcare and social services.

Via:  http://goo.gl/l9T56B Purchase full article at: http://goo.gl/JWHwxS

By: Fang SY1, Huang N1, Lin T1, Ho IK2, Chen CY3.

• 1Institute of Public Health, National Yang-Ming University, Taiwan.
• 2Center for Drug Abuse and Addiction, China Medical University, Taiwan; Graduate Institute of Clinical Medicine, China Medical University, Taiwan.
• 3Institute of Public Health, National Yang-Ming University, Taiwan; Center of Neuropsychiatric Research, National Health Research Institutes, Taiwan; College of Public Health, National Taiwan University, Taiwan 

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