Mitigating the regressivity of private mechanisms of financing healthcare: An Assessment of 29 countries.

Progressive financing of health care can help advance the equity and financial protection goals of health systems. All countries' health systems are financed in part through private mechanisms, including out-of-pocket payments and voluntary health insurance. Yet little is known about how these financing schemes are structured, and the extent to which policies in place mitigate regressivity. This study identifies the potential policies to mitigate regressivity in private financing, builds two qualitative tools to comparatively assess regressivity of these two sources of revenue, and applies this tool to a selection of 29 high-income countries. It provides new evidence on the variations in policy approaches taken, and resultant regressivity, of private mechanisms of financing health care. These results inform a comprehensive assessment of progressivity of health systems financing, considering all revenue streams, that appears in this special section of the journal.

Why do drinkers earn more? Job characteristics as a possible link.

After some initial controversy, an inverted U-shape relationship between the consumption of alcohol and earnings seems to be an established result, at least in North America. It has been dubbed a "drinking premium", at least in the lower portion of the consumption curve. It is still unclear, perhaps even counter-intuitive, why such a drinking premium exists and the literature suggests it is not causal but results rather from selection effects. We suggest here that part of the premium is linked to occupation: some occupations pay better, controlling for the usual human capital determinants, and also attract drinkers or induce workers to drink more. Using a sample of full-time employed or self-employed individuals aged 25-64 and not in poor health from the 2015-16 Canadian Community Health Survey (CCHS), we confirm the existence of a drinking premium and a positive return to the quantity or frequency of drinking up to high levels of consumption. Using information on jobs held by respondents, linked to a data set of job characteristics, we find that controlling for job characteristics reduces the premium or return to drinking by approximately 30% overall, and up to 50% for female workers.

Trajectories of the socioeconomic gradient of mental health: Results from the CLSA COVID-19 Questionnaire Study.

As the coronavirus disease (COVID-19) pandemic prolongs, documenting trajectories of the socioeconomic gradient of mental health is important. We describe changes in the prevalence and absolute and relative income-related inequalities of mental health between April and December 2020 in Canada. We used data from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Questionnaire Study and the pre-pandemic CLSA Follow-up 1. We estimated the prevalence proportion, the concentration index (relative inequality), and the generalized concentration index (absolute inequality) for anxiety and self-reported feeling generally unwell at multiple points in April-December 2020, overall, by sex and age group, by region, and among those who reported poor or fair overall health and mental health pre-pandemic. Overall, the prevalence of anxiety remained unchanged (22.45 to 22.10%, p = 0.231), but self-reported feeling generally unwell decreased (9.83 to 5.94%, p = 0.004). Relative and absolute income-related inequalities were unchanged for both anxiety and self-reported feeling generally unwell, with exceptions of an increased concentration of self-reported feeling generally unwell among the poor, measured by the concentration index, overall (-0.054 to -0.115, p = 0.004) and in Ontario (-0.035 to -0.123, p = 0.047) and British Columbia (-0.055 to -0.141, p = 0.044). The COVID-19 pandemic appeared to neither exacerbate nor ameliorate existing income-related inequalities in mental health among older adults in Canada between April and December 2020. Continued monitoring of inequalities is necessary.

A cross-sectional analysis of the association between social capital and willingness to get COVID-19 vaccine in Ontario, Canada.

OBJECTIVE: We examine the role of social capital in intention to take the vaccine at the end of the first wave of the COVID-19 pandemic. METHODS: This study uses observational, cross-sectional data from the Ontario sample of the fall 2020 Canadian Community Health Survey (CCHS), a representative sample of the population with added questions relative to symptoms of COVID-19 and intentions to get vaccinated. Questions on social capital were asked to respondents from Ontario only, yielding a sample of 6516. Odds ratios (OR) and marginal effects at sample mean of an index of social capital (at the individual or aggregated level) on changes in intentions to get vaccinated are estimated from logistic regression models. RESULTS: Individual-level social capital is associated with greater willingness to get vaccinated against COVID-19 (OR 1.09). Associations with aggregated-level social capital are less precisely estimated. Associations are the same for both males and females but vary across age categories: individual-level social capital is associated with higher willingness to get vaccinated among working-age respondents, but aggregate-level social capital is associated with higher willingness to get vaccinated among older adults. CONCLUSION: Vaccine hesitancy is not a random phenomenon, nor is it explained by individual characteristics such as education or income only. It also reflects the state of the social environment in which individuals live and public health messaging should take this into account if it is to be successful.

RéSUMé: OBJECTIF: Nous étudions le rôle du capital social dans les intentions de se faire vacciner à la fin de la première vague de la pandémie de COVID-19. MéTHODES: Ce travail utilise des données observationnelles transversales tirées de l'échantillon pour l'Ontario de la vague d'automne 2020 de l'Enquête sur la santé dans les collectivités canadiennes (ESCC), un échantillon représentatif de la population, en particulier des questions supplémentaires sur les symptômes de COVID-19 et les intentions de se faire vacciner. Les questions sur le capital social n'ont été posées qu'aux répondants vivant en Ontario, nous donnant un échantillon de taille N = 6 516. Les rapports de chances (RC) et les effets marginaux au point moyen de l'échantillon de l'indice de capital social (individuel ou agrégé) sur les changements de la santé mentale auto-déclarée ainsi que sur l'intention de se faire vacciner sont estimés à partir d'une régression logistique. RéSULTATS: Le capital social mesuré au niveau individuel est associé à des intentions plus élevées de se faire vacciner (RC de 1,09). L'association du capital social mesuré au niveau agrégé est moins précisément estimée et nous ne trouvons une association significativement différente de 0 qu'au seuil de 10 % seulement. Les associations sont les mêmes pour les hommes et les femmes mais varient selon la classe d'âge : le capital social individuel est associé à une intention élevée de se faire vacciner parmi les enquêtés en âge de travailler, mais le capital social agrégé est associé à une intention élevée de se faire vacciner parmi les enquêtés plus âgés. CONCLUSION: La réticence devant le vaccin n'est pas distribuée au hasard et n'est pas non plus expliquée seulement par les caractéristiques individuelles comme l'éducation ou le revenu. Elle reflète aussi l'état de l'environnement social dans lequel les individus vivent et les messages de santé publique doivent en tenir compte pour être efficaces.

"But I survived": A phenomenological study of the health and wellbeing of aging Black women in the Greater Toronto Area, Canada.

Studies that assess the association between race and health have focused intently on the cumulative impact of continuous exposure to racism over an extended period. While these studies have contributed significantly to the general understanding of the life experiences and health status of racialized people, few studies have explicitly bridged the experiences of aging with gender and the wide structural barriers and social factors that have shaped the lives of racialized older women. This study aimed to investigate the origins of health inequities to highlight factors that intersect to affect the health and wellbeing of older Black women across their life course. Descriptive phenomenology was used to describe older Black women's health and wellbeing, and factors that impact their health across their life course. Criteria-based sampling was used to recruit study participants (n = 27). To be eligible women needed to be 55 years or older, speak English, self-identify as a Black female, and live in the Greater Toronto Area. Data analysis was guided by phenomenology. Themes identified demonstrated that participants' health and wellbeing were influenced by gender bias, racism, abuse, and retirement later in life. Participants reported having poor mental health during childhood and adulthood due to anxiety and depression. Other chronic illnesses reported included hypertension, diabetes, and cancer. Qualitative methods provided details regarding events and exposures that illuminate pathways through which health inequities emerge across the life course.

The association between housing cost burden and avoidable mortality in wealthy countries: cross-national analysis of social and housing policies, 2000-2017.

BACKGROUND: It has been shown that the high cost of housing can be detrimental to individual health. However, it is unknown (1) whether high housing costs pose a threat to population health and (2) whether and how social policies moderate the link between housing cost burden and mortality. This study aims to reduce these knowledge gaps. METHODS: Country-level panel data from Organisation for Economic Co-operation and Development (OECD) countries are used. Housing cost to income ratio and age-standardised mortality were obtained from the OECD database. Fixed effects models were conducted to estimate the extent to which the housing cost to income ratio was associated with preventable mortality, treatable mortality, and suicides. In order to assess the moderating effects of social and housing policies, different types of social spending per capita as well as housing policies were taken into account. RESULTS: Housing cost to income ratio was significantly associated with preventable mortality, treatable mortality, and suicide during the post-global financial crisis (2009-2017) but not during the pre-global financial crisis (2000-2008). Social spending on pensions and unemployment benefits decreased the levels of mortality rate associated with housing cost burden. In countries with higher levels of social housing stock, the link between housing cost burden and mortality was attenuated. Similar patterns were examined for countries with rent control. CONCLUSION: Our findings suggest that housing cost burden can be related to population health. Future studies should examine the role of protective measures that alleviate health problems caused by housing cost burden.

How do housing asset and income relate to mortality? A population-based cohort study of 881220 older adults in Canada.

OBJECTIVE: A growing body of research has documented a well-established link between socioeconomic conditions and mortality among older adults. This study aims to understand (a) whether housing assets and income are associated with mortality and (b) if the value of housing assets affects the relationship between income and mortality; both questions are studied among older adults aged 65 or over in Canada. METHODS: Using the population-based linked dataset (2011 Canadian Census Health and Environment Cohorts) of 881,220 older adults over six years of follow-up (2011-2017), this study uses survival analysis to estimate the link between housing assets, income level and mortality. We also assess the potential moderating effect of housing asset levels on the association between income and mortality by categorizing individuals along two dimensions: whether they are income-poor and whether they are housing assets-poor. RESULTS: The mortality rate was higher among both the lowest asset (HR = 1.346) and the lowest income group (HR = 1.203). The association is pronounced for older adults aged 65 to 74. Assets did not significantly moderate the link between income and mortality. Income-related inequalities in mortality are observed among each group of housing asset level. Compared to those who are neither income-poor nor housing assets-poor, individuals who were income poor but not housing assets-poor were more likely to die (HR = 1.067) over seven years of follow-up, and people who were housing assets-poor only were more likely to die (HR = 1.210). Being housing-assets poor and income-poor yielded a higher hazard ratio (HR = 1.291). CONCLUSIONS: Housing assets and income are associated with mortality of older adults. It is important to identify people who are assets poor and/or income poor who are at higher risks of mortality. Social policies aimed at reducing income insecurity and housing insecurity can reduce mortality inequalities.

Food insecurity, home ownership and income-related equity in dental care use and access: the case of Canada.

BACKGROUND: It has been documented that income is a strong determinant of dental care use in Canada, mostly due to the lack of public coverage for dental care. We assess the contributions of food insecurity and home ownership to income-related equity in dental care use and access. We add to the literature by adding these two variables among other socio-economic determinants of equity in dental care use and access to dental care. Evidence on equity in access to and use of dental care in Canada can inform policymaking. METHODS: We estimate income-related horizontal inequity indexes for the probability of 1) receiving at least one dental visit in the last 12 months; and 2) lack of dental visits during the 3 years before the interview. We conduct the analyses using data from the 2013-2014 Canadian Community Health Survey (CCHS) at the national and regional level. RESULTS: There is pro-rich inequity in the probability of visiting a dentist or an orthodontist and in access to dental care in Ontario. Inequities vary across jurisdictions. Housing tenure and food insecurity contribute importantly to both use of and access to dental care, adding information not captured by standard socio-economic determinants. CONCLUSIONS: Redistributing income may not be enough to reduce inequities. Careful monitoring of equity in dental care is needed together with interventions targeting fragile groups not only in terms of income but also in improving house and food security.

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature.

BACKGROUND: It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it. PURPOSE OF STUDY: This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation. METHODS: Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes. RESULTS: Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs. CONCLUSION: Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

Cautionary tails of grip strength in health inequality studies: An analysis from the Canadian longitudinal study on aging.

Self-rated health is widely used in studies of the socioeconomic gradient of health in community-based populations. Its subjectivity may lead to under- or over-estimation of a true underlying socioeconomic gradient and has increased interest in searching for alternative, objective measures of health. Grip strength has emerged as one such alternative for community-based older populations, yet no study has directly assessed the relationship between these two measures and compared their associations with socioeconomic status and health behaviours. Using 26,754 participants aged 45-85 years in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort, we estimated adjusted-grip strength through indirect standardization using age, sex, height, weight, and their square terms and used ANOVA to assess the variance of adjusted-grip strength within and between each self-rated health category. We ran four separate logistic regression models, examining unhealthy tails (those reporting poor health vs. not and those at the bottom 8th percentile of adjusted-grip strength vs. above) and healthy tails (those reporting excellent health vs. not and those at the top 20th percentile of adjusted-grip strength vs. below). Stronger adjusted-grip strength correlated with better self-rated health, but only 2% of the total variance of adjusted-grip strength was explained by variance between the self-rated health categories. While self-rated health largely showed the expected socioeconomic gradients and positive relationships with health enhancing behaviours, adjusted-grip strength showed no clear, consistent associations with either socioeconomic or health behaviour variables. The results give caution about using grip strength as an objective alternative to self-rated health in studies of social inequalities in health. Empirical approaches demand careful considerations as to which dimensions of health and corresponding measures of health are most relevant to the context being studied.

Here comes the SUN: Self-assessed unmet need, worsening health outcomes, and health care inequity.

Utilization-based approaches have predominated the measurement of socioeconomic-related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access-self-reported unmet need (SUN)-which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self-reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization-based approaches.

Transnational wealth-related health inequality measurement.

The study of international differences in wealth-related health inequalities has traditionally consisted of country-by-country comparisons using own-country relative measures of socioeconomic status, which effectively ignores absolute differences in both wealth and health that can differ between and within countries. To address these limitations, we propose an alternative approach: that of constructing a transnational measure of wealth-related health inequality. To illustrate the limitations of the country-by-country approach, we simulate the impact of changes in wealth and health inequalities both between and within countries on cross-country measures of health inequality and find at least five errors that may arise using country-by-country methods. We then empirically demonstrate the transnational approach to wealth-related health inequalities between and within Haiti and the Dominican Republic, the two constituent countries of the island of Hispaniola, using data from their respective Demographic and Health Surveys. Transnational socioeconomic rankings reveal a large and increasing divergence in wealth between the two countries, which would be ignored using the county-by-country approach. We find that wealth-related inequalities in long-term children's health outcomes are larger than inequalities in short-term health outcomes, and decompositions of the influence of place-based variables on these inequalities reveal country of residence to be the most important factor for long-term outcomes, while urban/rural residence and subnational regions are more important for short-term health outcomes. The significance of this novel methodological approach in relation to conventional health inequality research, including hidden dimensions of wealth-related health inequalities, for example the urbanized "middle class" distribution of HIV and a hidden unequal burden of wasting among children uncovered by the transnational approach are discussed, and errors in gauging changes in inequality over time using a country-by-country approach are highlighted. Using the transnational approach can help to measure important trends in wealth-related health inequalities across countries that more commonly used methods traditionally overlook.

Health inequalities and inequities by age: Stability for the Health Utilities Index and divergence for the Frailty Index.

Successful aging is an important policy goal in an aging society. A key indicator of successful aging of a population is whether health inequalities (differences) and inequities (unfair differences) in the population increase or decrease with age. This study investigates how health inequalities and inequities differ across age groups in the Canadian population within the equity framework of equal opportunity for health, using two popular measures of health, the Health Utilities Index Mark 3 (HUI) and the Frailty Index (FI). We use the 2009-10 Canadian Health Measures Survey. We first quantify the degree of health inequality by calculating the Gini coefficient for the distributions of the HUI and the FI within three age groups (20-44, 45-64, and 65-79 years). We then identify sources of health inequality by using regression models and decomposing inequality into ethically acceptable and unacceptable components. We finally quantify the degree of health inequity by calculating the Gini coefficient for each health measure and each age group after standardizing for fairness. We find that the magnitudes of inequality and inequity in the HUI and the FI in each of the three age groups are policy relevant. The magnitude and age-related dynamics of health inequality and inequity depend on the choice of the health measures. In all three age groups, inequality and inequity in health measured by the HUI are larger than those measured by the FI. Across the three age groups, inequality and inequity are stable in the HUI but divergent in the FI. This study contributes to the methodological development to support policies for successful aging. Examination of alternative notions of health captured by the HUI and the FI contributes to the exploration of how the fair distribution of each aspect of health may characterize a successfully aging population.

The Funding of Long-Term Care in Canada: What Do We Know, What Should We Know?

ABSTRACTLong-term care is a growing component of health care spending but how much is spent or who bears the cost is uncertain, and the measures vary depending on the source used. We drew on regularly published series and ad hoc publications to compile preferred estimates of the share of long-term care spending in total health care spending, the private share of long-term care spending, and the share of residential care within long-term care. For each series, we compared estimates obtainable from published sources (CIHI [Canadian Institute for Health Information] and OECD [Organization for Economic Cooperation and Development]) with our preferred estimates. We conclude that using published series without adjustment would lead to spurious conclusions on the level and evolution of spending on long-term care in Canada as well as on the distribution of costs between private and public funders and between residential and home care.

The Determinants of the Technical Efficiency of Acute Inpatient Care in Canada.

OBJECTIVE: To evaluate the technical efficiency of acute inpatient care at the pan-Canadian level and to explore the factors associated with inefficiency-why hospitals are not on their production frontier. DATA SOURCES/STUDY SETTING: Canadian Management Information System (MIS) database (CMDB) and Discharge Abstract Database (DAD) for the fiscal year of 2012-2013. STUDY DESIGN: We use a nonparametric approach (data envelopment analysis) applied to three peer groups (teaching, large, and medium hospitals, focusing on their acute inpatient care only). The double bootstrap procedure (Simar and Wilson 2007) is adopted in the regression. DATA COLLECTION/EXTRACTION METHODS: Information on inpatient episodes of care (number and quality of outcomes) was extracted from the DAD. The cost of the inpatient care was extracted from the CMDB. PRINCIPAL FINDINGS: On average, acute hospitals in Canada are operating at about 75 percent efficiency, and this could thus potentially increase their level of outcomes (quantity and quality) by addressing inefficiencies. In some cases, such as for teaching hospitals, the factors significantly correlated with efficiency scores were not related to management but to the social composition of the caseload. In contrast, for large and medium nonteaching hospitals, efficiency related more to the ability to discharge patients to postacute care facilities. The efficiency of medium hospitals is also positively related to treating more clinically noncomplex patients. CONCLUSIONS: The main drivers of efficiency of acute inpatient care vary by hospital peer groups. Thus, the results provide different policy and managerial implications for teaching, large, and medium hospitals to achieve efficiency gains.

Uncomfortable trade-offs: Canadian policy makers' perspectives on setting objectives for their health systems.

BACKGROUND: Although a wide range of health system performance indicators are commonly reported on, there has been little effort to establish their relevance to the objectives that health systems actually pursue. OBJECTIVE: The aim of this study was to identify, explore and better understand health policy makers' views regarding the objectives and outcomes for their health systems, how they are prioritized, and the underlying processes that yield them to inform the development of health system efficiency measures. METHODS: A descriptive, qualitative methodology was employed using key informant interviews with 17 current and former senior health ministry officials in 8 Canadian provinces and 2 territories. KEY FINDINGS: Health ministries have clearly stated objectives for health systems focused on the achievement of health system delivery and population health goals and, increasingly, public, patient and financial accountability. Acute care objectives are routinely prioritized over population health objectives and viewed as resulting from challenges associated with difficult trade-off decisions shaped by organized interests and the media rather than explicit, evidence-based processes. CONCLUSION: This study provides insights beyond publicly available documents to explore the processes that underlie simple statements of health system objectives. Our findings suggest that despite respondents giving priority to improving individual and population health, it is more commonly portrayed as an ideal objective than as a realistic one. By understanding what lies behind statements about what health systems are striving for, we offer a more robust avenue for increasing the uptake of future studies of health system performance.