Int J Health Serv
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The objective of this study was to use audited hospital financial statements to identify predictors of payer mix and financial performance in safety net hospitals prior to the Affordable Care Act. We analyzed the 2010 financial statements of 98 large, urban safety net hospital systems in 34 states, supplemented with data on population demographics, hospital features, and state policies. We used multivariate regression to identify independent predictors of three outcomes: 1) Medicaid-reliant payer mix (hospitals for which at least 25% of hospital days are paid for by Medicaid); 2) safety net revenue-to-cost ratio (Medicaid and Medicare Disproportionate Share Hospital payments and local government transfers, divided by charity care costs and Medicaid payment shortfall); and 3) operating margin. ⋯ Safety net hospital financial performance varied considerably. Academic hospitals had higher operating margins, while more generous Medicaid eligibility and reimbursement policies improved hospitals' ability to recoup costs. Institutional and state policies may outweigh patient demographics in the financial health of safety net hospitals.
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The Affordable Care Act (ACA) was enacted in 2010 as the signature domestic achievement of the Obama presidency. It was intended to contain costs and achieve near-universal access to affordable health care of improved quality. Now, five years later, it is time to assess its track record. ⋯ More fundamental reform will be needed. The country still needs to confront the challenge that our for-profit health insurance industry, together with enormous bureaucratic waste and widespread investor ownership throughout our market-based system, are themselves barriers to health care reform. Here we consider the lessons we can take away from the ACA's first five years and lay out the economic, social/political, and moral arguments for replacing it with single-payer national health insurance.
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Historical Article
Beyond the Biomedical Paradigm: The Formation and Development of Indigenous Community-Controlled Health Organizations in Australia.
This article describes the formation and development of Aboriginal Community-Controlled Health Services in Australia, with emphasis on the Redfern Aboriginal Medical Service in Sydney. These organizations were established in the 1970s by Indigenous Australians who were excluded from and denied access to mainstream health services. The aim of this research was to explore notions of Indigenous agency against a historical backdrop of dispossession, colonialism, and racism. ⋯ This study examined their philosophy of healthcare, the range of services provided, their problems with state bureaucracies and government funding bodies, and the imposition of managerialist techniques and strategies on their governance. Essentially, these organizations transcend individualistic, biomedical, and bureaucratic paradigms of health services by conceptualizing and responding to Indigenous health needs at a grassroots level and in a broad social and political context. They are based on a social model of health.
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This short article, based on a presentation at the London School of Economics, criticizes the common opinion that "green growth" offers a relatively painless - some even say pain-free - transition path for capitalist economies. After a brief summary of the daunting arithmetic entailed in combining fast decarbonization with continuing growth, the article advances 3 propositions. First, market-based carbon mitigation programs, such as carbon trading, cannot be sufficient and must be coupled with other policy pillars that foster transformative investment and widespread regulation. ⋯ Third, more radical policies on both consumption and production are called for, to ensure that carbon mitigation is not pursued at the expense of equity and social welfare. These include policies to restrain high-carbon luxury consumption and a transition toward shorter paid working time. The conclusion is that a realistic program of green growth will be immensely difficult and entail radical political change.
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While the current Ebola epidemic spiraled out of control to become the biggest in history, the global public health response has been criticized as "too little, too late." Many, like the World Health Organization, are asking what lessons have been learned from this epidemic. We present an analysis of the political economy of this Ebola outbreak that reveals the importance of addressing the social determinants that facilitated the exposure of populations, previously unaffected by Ebola Virus Disease, to infection and restricted the capacity for an effective medical response. To prevent further such crises, the global public health community has a responsibility to advocate for health system investment and development and for fundamental pro-poor changes to economic and power relations in the region.