Antidiscrimination Laws as Essential Tools for Achieving LGBTQ+ Health Equity

This Viewpoint discusses a pending US Supreme Court case to determine the extent to which people who identify as LGBTQ+ are protected under state antidiscrimination laws in the commercial marketplace.

Now Is Our Time to Act: Why Academic Medicine Must Embrace Community Collaboration as Its Fourth Mission

In his Leadership Plenary at the Association of American Medical Colleges (AAMC) annual meeting, "Learn Serve Lead 2020: The Virtual Experience," president and CEO David Skorton emphasized that the traditional tripartite mission of academic medicine-medical education, clinical care, and research-is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine's missions. This means going beyond "delivering care" to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed. It means appreciating community assets and creating ongoing pathways for listening to and learning from the needs, lived experiences, perspectives, and wisdom of patients, families, and communities. It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities. The authors call on academic medical institutions to do more to build a strong network of collaborators across public and population health, government, community groups, and the private sector. We in academic medicine must hold ourselves accountable for weaving community collaborations consistently throughout research, medical education, and clinical care. The authors recognize the AAMC can do better to support its member institutions in doing so and discuss new initiatives that signify a shift in emphasis through the association's new strategic plan and AAMC Center for Health Justice. The authors believe every area of academic medicine could grow and better serve communities by listening and engaging more and bringing medical care, public health, and other sectors closer together.

Social and Behavioral Variables in the Electronic Health Record: A Path Forward to Increase Data Quality and Utility

PURPOSE

Social and behavioral determinants of health (SBDH) are important factors that affect the health of individuals but are not routinely captured in a structured and systematic manner in electronic health records (EHRs). The purpose of this study is to generate recommendations for systematic implementation of SBDH data collection in EHRs through (1) reviewing SBDH conceptual and theoretical frameworks and (2) eliciting stakeholder perspectives on barriers to and facilitators of using SBDH information in the EHR and priorities for data collection.

METHOD

The authors reviewed SBDH frameworks to identify key social and behavioral variables and conducted focus groups and interviews with 17 clinicians and researchers at Johns Hopkins Health System between March and May 2018. Transcripts were coded and common themes were extracted to understand the barriers to and facilitators of accessing SBDH information.

RESULTS

The authors found that although the frameworks agreed that SBDH affect health outcomes, the lack of model consensus complicates the development of specific recommendations for the prioritization of SBDH data collection. Study participants recognized the importance of SBDH information and individual health and agreed that patient-reported information should be captured, but clinicians and researchers cited different priorities for which variables are most important. For the few SBDH variables that are captured, participants reported that data were often incomplete, unclear, or inconsistent, affecting both researcher and clinician responses to SBDH barriers to health.

CONCLUSIONS

Health systems need to identify and prioritize the systematic implementation of collection of a high-impact but limited list of SBDH variables in the EHR. These variables should affect care and be amenable to change and collection should be integrated into clinical workflows. Improved data collection of SBDH variables can lead to a better understanding of how SBDH affect health outcomes and ways to better address underlying health disparities that need urgent action.

Navigating inequities: a roadmap out of the pandemic

The COVID-19 pandemic has exposed social inequities that rival biological inequities in disease exposure and severity. Merely identifying some inequities without understanding all of them can lead to harmful misrepresentations and deepening disparities. Applying an 'equity lens' to bring inequities into focus without a vision to extinguish them is short-sighted. Interventions to address inequities should be as diverse as the pluralistic populations experiencing them. We present the first validated equity framework applied to COVID-19 that sheds light on the full spectrum of health inequities, navigates their sources and intersections, and directs ethically just interventions. The Equity Matrix also provides a comprehensive map to guide surveillance and research in order to unveil epidemiological uncertainties of novel diseases like COVID-19, recognising that inequities may exist where evidence is currently insufficient. Successfully applied to vaccines in recent years, this tool has resulted in the development of clear, timely and transparent guidance with positive stakeholder feedback on its comprehensiveness, relevance and appropriateness. Informed by evidence and experience from other vaccine-preventable diseases, this Equity Matrix could be valuable to countries across the social gradient to slow the spread of SARS-CoV-2 by abating the spread of inequities. In the race to SARS-CoV-2 vaccines, this urgently needed roadmap can effectively and efficiently steer global leadership towards equitable allocation with diverse strategies for diverse inequities. Such a roadmap has been absent from discussions on managing the COVID-19 pandemic, and is critical for our passage out of it.

Cancer Disparities and Health Equity: A Policy Statement From the American Society of Clinical Oncology

ASCO strives, through research, education, and promotion of the highest quality of patient care, to create a world where cancer is prevented and every survivor is healthy. In this pursuit, cancer health equity remains the guiding institutional principle that applies to all its activities across the cancer care continuum. In 2009, ASCO committed to addressing differences in cancer outcomes in its original policy statement on cancer disparities. Over the past decade, despite novel diagnostics and therapeutics, together with changes in the cancer care delivery system such as passage of the Affordable Care Act, cancer disparities persist. Our understanding of the populations experiencing disparate outcomes has likewise expanded to include the intersections of race/ethnicity, geography, sexual orientation and gender identity, sociodemographic factors, and others. This updated statement is intended to guide ASCO's future activities and strategies to achieve its mission of conquering cancer for all populations. ASCO acknowledges that much work remains to be done, by all cancer stakeholders at the systems level, to overcome historical momentum and existing social structures responsible for disparate cancer outcomes. This updated statement affirms ASCO's commitment to moving beyond descriptions of differences in cancer outcomes toward achievement of cancer health equity, with a focus on improving equitable access to care, improving clinical research, addressing structural barriers, and increasing awareness that results in measurable and timely action toward achieving cancer health equity for all.

The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review

BACKGROUND

Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum.

METHODS

A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria.

RESULTS

A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities.

CONCLUSIONS

Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.

Supports and gaps in federal policy for addressing racial and ethnic disparities among long-term care facility residents

Older adults from racial and ethnic minority groups are likely to face disparities in their health as well as care experiences in long-term care facilities such as nursing homes and assisted living facilities just as they do in the United States as a whole. Policymakers in the United States face concerns around long-term services and supports to address the growing demands of a rapidly aging population through public and private sector initiatives. It is important to create inclusive and culturally responsive environments to meet the needs of diverse groups of older adults. In spite of federal policy that supports minority health and protects the well-being of long-term care facility residents, racial and ethnic disparities persist in long-term care facilities. This manuscript describes supports and gaps in the current United States' federal policy to reduce racial and ethnic disparities in long-term care facilities. Implications for social workers are discussed and recommendations include efforts to revise portions of the Patient Protection and Affordable Care Act of 2010, amending regulations regarding long-term care facilities' training and oversight, and tailoring the Long-Term Care Ombudsman Program's data collection, analysis, and reporting requirements to include racial and ethnic demographic data.

Generating Global Priority for Addressing Rheumatic Heart Disease: A Qualitative Policy Analysis

Background Rheumatic heart disease (RHD) poses a high burden in low-income countries, as well as among indigenous and other socioeconomically disadvantaged populations in high-income countries. Despite its severity and preventability, RHD receives insufficient global attention and resources. We conducted a qualitative policy analysis to investigate the reasons for recent growth but ongoing inadequacy in global priority for addressing RHD. Methods and Results Drawing on social science scholarship, we conducted a thematic analysis, triangulating among peer-reviewed literature, organizational documents, and 20 semistructured interviews with individuals involved in RHD research, clinical practice, and advocacy. The analysis indicates that RHD proponents face 3 linked challenges, all shaped by the nature of the issue. With respect to leadership and governance, the fact that RHD affects mostly poor populations in dispersed regions complicates efforts to coordinate activities among RHD proponents and to engage international organizations and donors. With respect to solution definition, the dearth of data on aspects of clinical management in low-income settings, difficulties preventing and addressing the disease, and the fact that RHD intersects with several disease specialties have fueled proponent disagreements about how best to address the disease. With respect to positioning, a perception that RHD is largely a problem for low-income countries and the ambiguity on its status as a noncommunicable disease have complicated efforts to convince policy makers to act. Conclusions To augment RHD global priority, proponents will need to establish more effective governance mechanisms to facilitate collective action, manage differences surrounding solutions, and identify positionings that resonate with policy makers and funders.

Perceptions of Protection under Nondiscrimination Law

Nondiscrimination rules-statutes, regulations, and soft law protections-are critical for reducing health and health care disparities. Although scholarship has interrogated how nondiscrimination rules affect behavior by discriminators, comparatively little has considered how protections can affect choices made by members of protected groups. A number of states and some interpretations of federal law protect people from discrimination on the basis of sexual orientation. This Article seeks to identify relationships between actual state law, perceived state law, and experiences of discrimination and medical mistrust. This Article reports the results of a national cross-sectional survey of over 3,000 men using Grindr to meet male partners. Participants scored comparable to chance in knowledge about state nondiscrimination protections, with "optimistic errors" (erroneous beliefs that one was protected) significantly more common than pessimistic errors. Perceptions of protection were significantly correlated with lower medical mistrust and greater uptake of care, as well as lower perceived barriers to disclosure and care-seeking. Actual state law protections, however, were significant predictors of having had discussions with providers that depended on disclosure of sexual behavior or orientation. Building on these results, this Article considers pathways by which nondiscrimination law may exert welcome mat (and "unwelcome mat") effects.

Examining the impact of medical legal partnerships in improving outcomes on the HIV care continuum: rationale, design and methods

BACKGROUND

Over the past two decades, we have seen a nationwide increase in the use of medical-legal partnerships (MLPs) to address health disparities affecting vulnerable populations. These partnerships increase medical teams' capacity to address social and environmental threats to patients' health, such as unsafe housing conditions, through partnership with legal professionals. Despite expansions in the use of MLP care models in health care settings, the health outcomes efficacy of MLPs has yet to be examined, particularly for complex chronic conditions such as HIV.

METHODS

This on-going mixed-methods study utilizes institutional case study and intervention mapping methodologies to develop an HIV-specific medical legal partnership logic model. Up-to-date, the organizational qualitative data has been collected. The next steps of this study consists of: (1) recruitment of 100 MLP providers through a national survey of clinics, community-based organizations, and hospitals; (2) in-depth interviewing of 50 dyads of MLP service providers and clients living with HIV to gauge the potential large-scale impact of legal partnerships on addressing the unmet needs of this population; and, (3) the development of an MLP intervention model to improve HIV care continuum outcomes using intervention mapping.

DISCUSSION

The proposed study is highly significant because it targets a vulnerable population, PLWHA, and consists of formative and developmental work to investigate the impact of MLPs on health, legal, and psychosocial outcomes within this population. MLPs offer an integrated approach to healthcare delivery that seems promising for meeting the needs of PLWHA, but has yet to be rigorously assessed within this population.

Disrupting gender norms in health systems: making the case for change

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Gender equality and gender norms: framing the opportunities for health

The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the substantial impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper, the fifth in a Series on gender equality, norms, and health, we draw on evidence to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms.

Inequalities in realised access to healthcare among recently arrived refugees depending on local access model: study protocol for a quasi-experimental study

INTRODUCTION

In many countries, including Germany, newly arriving refugees face specific entitlement restrictions and access barriers to healthcare. While entitlement restrictions apply to all refugees who seek protection in Germany during the first months, the barriers to access depend on the model that the states and the municipalities implement locally. Currently, two different models exist: the healthcare voucher model (HcV) and the electronic health card model (eHC). The aim of the study is to analyse the consequences of these two different access models on newly arrived refugees' realised access to healthcare.

METHODS AND ANALYSIS

The random assignment of refugees to municipalities allows for a quasi-experimental design by comparing realised access to healthcare among refugees in six municipalities in North Rhine-Westphalia which have implemented HcV or eHC. We compare realised access to healthcare using ambulatory care sensitive conditions and health expenditure as outcome indicators, and use of emergency care, preventive care, psychotherapeutic or psychiatric care, and of therapeutic devices as process indicators. Results will be adjusted for aggregated information on age, sex, socioeconomic structure of the municipalities and density of general practitioners or specialists.

ETHICS AND DISSEMINATION

We cooperated with local welfare offices and the statutory health insurance for data collection. Thereby, we were able to avoid recruiting large numbers of refugee patients immediately after arrival while their access and entitlement to healthcare are restricted. We developed an extensive data protection concept and ensured that all data collected are fully anonymised. Results will be published in peer-reviewed journals and summarised in reports to the funding agency.

The Structural Violence of Hyperincarceration - A 44-Year-Old Man with Back Pain

Mr. M., an uninsured, 44-year-old Puerto Rican man with chronic back pain, diabetes, hypertension, asthma, and a history of incarceration presented to a free clinic with acute exacerbation of back pain triggered by carrying heavy loads of trash at work. A premedical student acting as his health care advocate accompanied him. Mr. M. was hesitant to seek health care because he had no health insurance and mistrusted institutions as a result of his extensive negative experiences with the criminal justice system. He was visibly nervous in the unfamiliar institutional environment of the clinic, which had no Latino staff and was located in a middle-class neighborhood far from his home. The advocate reassured him in Spanish that the doctor was trustworthy and urged him to speak frankly about his health problems, including his challenges in obtaining medication. Embarrassed, Mr. M. reported that during recent back-pain exacerbations he occasionally resorted to purchasing one or two 5-mg oxycodone tablets in the open-air drug market operating on the inner-city block where he lived. The physician gave Mr. M. ibuprofen and a prescription for five 5-mg oxycodone tablets, enrolled him in the clinic’s diabetes and hypertension programs, and scheduled a follow-up visit. Mr. M. never filled the prescription and did not return to the clinic, despite repeated entreaties by the advocate both in person and over the phone. Mr. M.’s pain had eased, and he claimed to be managing his diabetes, hypertension, and asthma by splitting medication with insured family members. To stretch their supply, they rationed their doses for use only on the days when they “felt symptoms.” Finally, 8 months later, Mr. M. admitted that he had not dared fill his prescription or return to the clinic for fear of being rearrested after admitting to the doctor that he had purchased oxycodone illegally.

Effects of the ACA on Preventive Care Disparities

BACKGROUND

The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care.

OBJECTIVES

We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears.

METHODS

We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA.

RESULTS

After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status.

CONCLUSIONS

Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.

Cost-Effectiveness Analysis of a Navigation Program for Colorectal Cancer Screening to Reduce Social Health Inequalities: A French Cluster Randomized Controlled Trial

BACKGROUND

Patient navigation programs to increase colorectal cancer (CRC) screening adherence have become widespread in recent years, especially among deprived populations.

OBJECTIVES

To evaluate the cost-effectiveness of the first patient navigation program in France.

METHODS

A total of 16,250 participants were randomized to either the usual screening group (n = 8145) or the navigation group (n = 8105). Navigation consisted of personalized support provided by social workers. A cost-effectiveness analysis of navigation versus usual screening was conducted from the payer perspective in the Picardy region of northern France. We considered nonmedical direct costs in the analysis.

RESULTS

Navigation was associated with a significant increase of 3.3% (24.4% vs. 21.1%; P = 0.003) in participation. The increase in participation was higher among affluent participants (+4.1%; P = 0.01) than among deprived ones (+2.6%; P = 0.07). The cost per additional individual screened by navigation compared with usual screening (incremental cost-effectiveness ratio) was €1212 globally and €1527 among deprived participants. Results were sensitive to navigator wages and to the intervention effectiveness whose variations had the greatest impact on the incremental cost-effectiveness ratio.

CONCLUSIONS

Patient navigation aiming at increasing CRC screening participation is more efficient among affluent individuals. Nevertheless, when the intervention is implemented for the entire population, social inequalities in CRC screening adherence increase. To reduce social inequalities, patient navigation should therefore be restricted to deprived populations, despite not being the most cost-effective strategy, and accepted to bear a higher extra cost per additional individual screened.

Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review

This systematic review evaluates efforts to date to involve community health workers (CHWs) in delivering evidence-based mental health interventions to underserved communities in the United States and in low- and middle-income countries. Forty-three articles (39 trials) were reviewed to characterize the background characteristics of CHW, their role in intervention delivery, the types of interventions they delivered, and the implementation supports they received. The majority of trials found that CHW-delivered interventions led to symptom reduction. Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities. Areas for future research as well as clinical and policy implications are discussed.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

ISSUE: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care. GOAL: Assess the effect of the ACA’s major coverage expansions on disparities in access to care among adults. METHODS: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System. FINDINGS AND CONCLUSIONS: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA’s coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.

New Organ Allocation System for Combined Liver-Kidney Transplants and the Availability of Kidneys for Transplant to Patients with Stage 4-5 CKD

A new proposal has been created for establishing medical criteria for organ allocation in recipients receiving simultaneous liver-kidney transplants. In this article, we describe the new policy, elaborate on the points of greatest controversy, and offer a perspective on the policy going forward. Although we applaud the fact that simultaneous liver-kidney transplant activity will now be monitored and appreciate the creation of medical criteria for allocation in simultaneous liver-kidney transplants, we argue that some of the criteria proposed, especially those for allocating a kidney to a liver recipient with AKI, are too liberal. We call on the nephrology community to follow the consequences of this new policy and push for a re-examination of the longstanding policy of allocating kidneys to multiorgan transplant recipients before all other candidates. The charge to protect our system of equitable organ allocation is very challenging, but it is a challenge that we must embrace.

Age-related references in national public health, technology appraisal and clinical guidelines and guidance: documentary analysis

Background

older people may be less likely to receive interventions than younger people. Age bias in national guidance may influence entire public health and health care systems. We examined how English National Institute for Health & Care Excellence (NICE) guidance and guidelines consider age.

Methods

we undertook a documentary analysis of NICE public health (n = 33) and clinical (n = 114) guidelines and technology appraisals (n = 212). We systematically searched for age-related terms, and conducted thematic analysis of the paragraphs in which these occurred (‘age-extracts’). Quantitative analysis explored frequency of age-extracts between and within document types. Illustrative quotes were used to elaborate and explain quantitative findings.

Results

2,314 age-extracts were identified within three themes: age documented as an a-priori consideration at scope-setting (518 age-extracts, 22.4%); documentation of differential effectiveness, cost-effectiveness or other outcomes by age (937 age-extracts, 40.5%); and documentation of age-specific recommendations (859 age-extracts, 37.1%). Public health guidelines considered age most comprehensively. There were clear examples of older-age being considered in both evidence searching and in making recommendations, suggesting that this can be achieved within current processes.

Conclusions

we found inconsistencies in how age is considered in NICE guidance and guidelines. More effort may be required to ensure age is consistently considered. Future NICE committees should search for and document evidence of age-related differences in receipt of interventions. Where evidence relating to effectiveness and cost-effectiveness in older populations is available, more explicit age-related recommendations should be made. Where there is a lack of evidence, it should be stated what new research is needed.

The HIV Organ Policy Equity Act: Offering Hope to Individuals with End Stage Renal Disease and HIV

The HIV Organ Policy Equity Act, or HOPE Act, requires the Secretary of Health and Human Services to develop guidelines for research on the transplantation of kidneys and livers from individuals infected with the human immunodeficiency virus (HIV) into patients with end stage organ failure who are also infected with HIV. Although signed into law in 2013, the guidelines were not finalized until November 2015. Currently, 18 transplant centers that wish to participate in this research have received Institutional Review Board approval. The HOPE Act is expected to expand the donor pool by approximately 500 to 600 per year in the United States and reduce wait times for HIV-infected patients as well as those not infected with the virus. South Africa, a country that began HIV+ to HIV+ transplants several years ago, has demonstrated encouraging patient and graft survival rates. The extent to which these results will be replicated in the United States is unknown. The outcomes experienced by patients and transplant centers that participate in the HOPE Act research will determine if the practice of transplanting HIV-infected organs will one day be considered for more widespread use in the United States.

Primary or specialist medical care: Which is more equitable? A policy brief

BACKGROUND

Equity in health and equitable access to healthcare has been at the core of health policy in India. The key policy challenge has been how to make that possible? Various health insurance schemes such as the Rashtriya Swasthya Bima Yojana and Arogyasri seek to improve poor people's access to specialist medical care in the public and private sectors. On the other hand, access to primary medical care has been left to the supply side interventions.

METHODS

We did a focused review of evidence on equity aspects of primary medical care versus specialist medical care. We selected relevant publications from the Cochrane Library, PubMed and Google Scholar searches and articles snowballing out of them.

RESULTS

Higher primary care physician-to-population ratio is invariably associated with better health outcomes. Primary care may partly protect the poor from adverse effects of income inequality on health status. On the other hand, populations do not necessarily benefit from an overabundance of specialists in a geographical area.

CONCLUSIONS

Three key policy lessons emerge from this review. First, states should strengthen primary medical care by upgrading health centres. Second, a family health protection plan should be introduced as a demand side intervention to deliver primary care through health centres, non-profit and for-profit clinics. Third, postgraduate courses in family medicine should be introduced for a balanced development of the specialty of primary care pari passu other specialties.

Health Care's Other "Big Deal": Direct Primary Care Regulation in Contemporary American Health Law

Direct primary care is a promising, market-based alternative to the fee-for-service payment structure that shapes doctor–patient relationships in America. Instead of billing patients and insurers service by service, direct primary care doctors charge their patients a periodic, prenegotiated fee in exchange for providing a wide range of healthcare services and increased availability compared to traditional practices. This “subscription” model is intended to eliminate the administrative burdens associated with insurer interaction, which, in theory, allows doctors to spend more time with their patients and less time doing paperwork. Direct practices have become increasingly popular since Congress passed the Affordable Care Act (ACA). This growth has been driven by legislation in several states that resolves a number of legal questions that slowed the model’s growth and by the ACA’s recognition of the model as a permissible way to cover primary care in "approved" health plans. Yet legal scholars have hardly focused on direct primary care. Given the model’s growth, however, the time is ripe for a more focused legal inquiry. This Note begins that inquiry. After tracing the model’s evolution and its core components, this Note substantively examines the laws in states that regulate direct practices and analyzes how those laws address a number of potential policy concerns. It then analyzes direct primary care’s broader role in the contemporary American healthcare marketplace. Based upon that analysis, this Note concludes that direct primary care is a beneficial innovation that harmonizes well with a cooperative-federalism-based healthcare policy model.

Women's Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk

Issue: Since enactment of the Affordable Care Act (ACA), many more women have health insurance than before the law, in part because it prohibits insurer practices that discriminate against women. However, gaps in women's health coverage persist. Insurers often exclude health services that women are likely to need, leaving women vulnerable to higher costs and denied claims that threaten their economic security and physical health. Goal: To uncover the types and incidence of insurer exclusions that may disproportionately affect women's coverage. Method: The authors examined qualified health plans from 109 insurers across 16 states for 2014, 2015, or both years. Key findings and conclusions: Six types of services are frequently excluded from insurance coverage: treatment of conditions resulting from noncovered services, maintenance therapy, genetic testing, fetal reduction surgery, treatment of self-inflicted conditions, and preventive services not covered by law. Policy change recommendations include prohibiting variations within states' "essential health benefits" benchmark plans and requiring transparency and simplified language in plan documents.

Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice

This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine.

Hypertension Prevalence, Awareness, Treatment, and Control Following China's Healthcare Reform

BACKGROUND

In 2009, China started an impressive national healthcare system reform. One of the key components is to promote equity in access to essential healthcare services including chronic disease management. We assessed the changes in hypertension management and its equity before and after China's healthcare reform in 2009.

METHODS

We used data from the 2008 and 2012 waves of the China Health and Retirement Longitudinal Study (CHARLS). The surveys were conducted in Zhejiang and Gansu provinces, containing 1,961 and 1,836 respondents aged 45 and older in 2008 and 2012 respectively. We measured the prevalence of hypertension, and proportions of respondents with hypertension aware of their conditions, receiving treatment and under effective control, separately for 2008 and 2012. We also reported these measures in provinces and rural/urban areas.

RESULTS

From 2008 to 2012, the age standardized prevalence of hypertension was steady at 46.2%, but hypertension management improved substantially. Among those with hypertension, the proportion of patients aware of their conditions increased from 57.8% to 69.9%, the proportion of patients receiving treatment increased from 38.1% to 56.1%, and the proportion of patients with hypertension under effective control increased from 21.7% to 36.4%. The highest improvement was found in rural areas of the underdeveloped province, which indicated that the inequity across regions declined over time.

CONCLUSIONS

Among Chinese population aged 45 and older in Zhejiang and Gansu provinces, hypertension management improved following healthcare reform. The rate of improvement was faster in rural and underdeveloped areas, possibly related to additional governmental subsidies to these areas.

Legally invisible: stewardship for Aboriginal and Torres Strait Islander health

OBJECTIVES

The need to improve access to good health care for Aboriginal and Torres Strait Islander people has been the subject of policy debate for decades, but progress is hampered by complex policy and administrative arrangements and lack of clarity about the responsibilities of governments. This study aimed to identify the current legal basis of those responsibilities and define options available to Australian governments to enact enduring responsibility for Aboriginal health care.

METHODS

This study used a framework for public health law research and conducted a mapping study to examine the current legal underpinnings for stewardship and governance for Aboriginal health and health care. More than 200 pieces of health legislation were analysed in the context of the common and statutory law and health policy goals.

RESULTS

Very little specific recognition of the needs of Aboriginal people was found, and nothing that creates responsibility for stewardship and governance. The continuing absence of a legislative framework to address and protect Aboriginal health can be traced back to the founding doctrine of terra nullius (unoccupied land).

CONCLUSIONS

We considered the results applying both a human rights perspective and the perspective of therapeutic jurisprudence. We suggest that national law for health stewardship would provide a strong foundation for progress, and should itself be based on recognition of Australia's First Peoples in the Australian Constitution, as is currently proposed.

Medicaid and Children's Health Insurance Programs; Mental Health Parity and Addiction Equity Act of 2008; the Application of Mental Health Parity Requirements to Coverage Offered by Medicaid Managed Care Organizations, the Children's Health Insurance Program (CHIP), and Alternative Benefit Plans. Final rule

This final rule will address the application of certain requirements set forth in the Public Health Service Act, as amended by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, to coverage offered by Medicaid managed care organizations, Medicaid Alternative Benefit Plans, and Children’s Health Insurance Programs.

Medicaid expansion and access to care among cancer survivors: a baseline overview

PURPOSE

Medicaid expansion under the Affordable Care Act facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Medicaid expansions may provide increased access to care for cancer survivors, a growing population with chronic conditions. We compare access to health care services among cancer survivors living in non-expansion states to those living in expansion states, prior to Medicaid expansion under the Affordable Care Act.

METHODS

We use the 2012 and 2013 Behavioral Risk Factor Surveillance System to estimate multiple logistic regression models to compare inability to see a doctor because of cost, having a personal doctor, and receiving an annual checkup in the past year between cancer survivors who lived in non-expansion states and survivors who lived in expansion states.

RESULTS

Cancer survivors in non-expansion states had statistically significantly lower odds of having a personal doctor (adjusted odds ratio [AOR] 0.76, 95 % confidence interval [CI] 0.63-0.92, p < 0.05) and higher odds of being unable to see a doctor because of cost (AOR 1.14, 95 % CI 0.98-1.31, p < 0.10). Statistically significant differences were not found for annual checkups.

CONCLUSIONS

Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors with limited access to routine care.

IMPLICATIONS FOR CANCER SURVIVORS

Existing disparities in access to care are likely to widen between cancer survivors in Medicaid non-expansion and expansion states.

ACCESS OF SINGLE WOMEN TO FERTILITY TREATMENT: A CASE OF INCIDENTAL DISCRIMINATION?

The purpose of this article is to evaluate the extent to which single women have access to publicly funded fertility treatment. It claims that, despite the fact that great progress has been made in removing gender inequalities in the area of assisted reproduction in England and Wales in recent years, there are points in the regulatory framework that still allow for discrimination against single women. The article builds on recent studies concerning the reforms brought about by the Human Fertilisation and Embryology Act 2008 (HFEA 2008). However, it focusses on publicly funded treatment, thus directing scholarly attention away from the controversies over the amended s 13(5) HFEA 1990. It argues that the primary reason for remaining inequalities can be traced back to (a) the limitations of the current legislative framework; (b) the ambiguities inherent in the regulatory framework, which in the context of publicly funded fertility treatment is determined by the National Institute for Health and Care Excellence clinical guidelines and Clinical Commissioning Groups and Health Boards' resource allocation policies; and (c) the remaining confusion about the relationship between 'welfare of the child' assessments and eligibility criteria in National Health Service rationing decisions. The article argues that the current regulation does not go far enough in acknowledging the inability of single women to conceive naturally, but at the same time that it struggles to address the fluidity of contemporary familial relationships. The analysis presents an opportunity to contribute to debates about the role of law in shaping the scope of reproductive autonomy, gender equality and social justice.

Organ procurement and transplantation: implementation of the HIV Organ Policy Equity Act. Final rule

This final rule amends the regulations implementing the National Organ Transplant Act of 1984, as amended, (NOTA) pursuant to statutory requirements of the HIV Organ Policy Equity Act (HOPE Act), enacted in 2013. In accordance with the mandates of the HOPE Act, this regulation removes the current regulatory provision that requires the Organ Procurement Transplantation Network (OPTN) to adopt and use standards for preventing the acquisition of organs from individuals known to be infected with human immunodeficiency virus (HIV). In its place, this regulation includes new requirements that organs from individuals infected with HIV may be transplanted only into individuals who are infected with HIV before receiving such organs and who are participating in clinical research approved by an institutional review board, as provided by regulation. The only exception to this requirement of participation in such clinical research is if the Secretary publishes a determination in the future that participation in such clinical research, as a requirement for transplants of organs from individuals infected with HIV, is no longer warranted. In addition, this regulatory change establishes that OPTN standards must ensure that any HIV-infected transplant recipients are participating in clinical research in accordance with the research criteria to be published by the Secretary. Alternately, if and when the Secretary determines that participation in such clinical research should no longer be a requirement for transplants with organs from donors infected with HIV to individuals infected with HIV, the regulation mandates that the OPTN adopt and use standards of quality, as directed by the Secretary, consistent with the law and in a way that ensures the changes will not reduce the safety of organ transplantation.