The fragmented and inefficient healthcare system in the United States leads to many preventable deaths and unnecessary costs every year. During a pandemic, the lives saved and economic benefits of a single-payer universal healthcare system relative to the status quo would be even greater. For Americans who are uninsured and underinsured, financial barriers to COVID-19 care delayed diagnosis and exacerbated transmission. Concurrently, deaths beyond COVID-19 accrued from the background rate of uninsurance. Universal healthcare would alleviate the mortality caused by the confluence of these factors. To evaluate the repercussions of incomplete insurance coverage in 2020, we calculated the elevated mortality attributable to the loss of employer-sponsored insurance and to background rates of uninsurance, summing with the increased COVID-19 mortality due to low insurance coverage. Incorporating the demography of the uninsured with age-specific COVID-19 and nonpandemic mortality, we estimated that a single-payer universal healthcare system would have saved about 212,000 lives in 2020 alone. We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a single-payer universal healthcare system over the course of the pandemic. These economic benefits are in addition to US$438 billion expected to be saved by single-payer universal healthcare during a nonpandemic year.
IMPORTANCENovel treatments for hepatitis C virus (HCV) infection are highly efficacious but costly.Thus, many insurers cover therapy only in advanced fibrosis stages.The added health benefits and costs of early treatment are unknown.OBJECTIVE To assess the cost-effectiveness of (1) treating all patients with HCV vs only those with advanced fibrosis and ( 2) treating each stage of fibrosis.DESIGN, SETTING, AND PARTICIPANTS This study used a decision-analytic model for the treatment of HCV genotype 1.The model used a lifetime horizon and societal perspective and was representative of all US patients with HCV genotype 1 who had not received previous treatment.Comparisons in the model included antiviral treatment of all fibrosis stages (METAVIR [Meta-analysis of Histological Data in Virial Hepatitis] stages F0 [no fibrosis] to F4 [cirrhosis]) vs treatment of stages F3 (numerous septa without cirrhosis) and F4 only and by specific fibrosis stage.Data were collected from March 1 to September 1, 2014, and analyzed from September 1, 2014, to June 30, 2015.INTERVENTIONS Six HCV therapy options (particularly combined sofosbuvir and ledipasvir therapy) or no treatment.MAIN OUTCOMES AND MEASURES Cost and health outcomes were measured using total medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), calculated as the difference in costs between strategies divided by the difference in QALYs. RESULTSWe simulated 1000 individuals, but present the results normalized to a single HCV-infected person.In the base-case analysis, among patients receiving 8 or 12 weeks of sofosbuvir-ledipasvir treatment, treating all fibrosis stages compared with treating stages F3 and F4 adds 0.73 QALYs and $28 899, for an ICER of $39 475 per QALY gained.Treating at stage F2 (portal fibrosis with rare septa) costs $19 833 per QALY gained vs waiting until stage F3; treating at stage F1 (portal fibrosis without septa), $81 165 per QALY gained compared with waiting until stage F2; and treating at stage F0, $187 065 per QALY gained compared with waiting until stage F1.Results for other regimens show a similar pattern.At base-case drug prices, treating 50% of all eligible US patients with HCV genotype 1 would cost $53 billion.In sensitivity analyses, the ICER for treating all stages vs treating stages F3 and F4 was most sensitive to cohort age, drug costs, utility values in stages F1 and F2, and percentage of patients eligible for 8-week therapy.Except for patients aged 70 years, the ICER remains less than $100 000 per QALY gained.A 46% reduction in cost of sofosbuvir-ledipasvir therapy decreases the ICER for treating at all fibrosis stages by 48%. CONCLUSIONS AND RELEVANCEIn this simulated model, treating HCV infection at early stages of fibrosis appeared to improve health outcomes and to be cost-effective but incurred substantial aggregate costs.The findings may have implications for health care coverage policies and clinical decision making.
We qualitatively assessed beliefs, attitudes, and behaviors related to diarrhea and water filtration in rural Kenya.A public health campaign was conducted in rural western Kenya to give community members a comprehensive prevention package of goods and services, including a personal water filter or a household water filter (or both). Two months after the campaign, we conducted qualitative interviews with 34 campaign attendees to assess their beliefs, attitudes, and behaviors related to diarrhea and use of the filtration devices.Participants held generally correct perceptions of diarrhea causation. Participants provided positive reports of their experiences with using filters and of their success with obtaining clean water, reducing disease, and reducing consumption of resources otherwise needed to produce clean water. Several participants offered technical suggestions for device improvements, and most participants were still using the devices at the time of the assessment.Novel water filtration devices distributed as part of a comprehensive public health campaign rapidly proved acceptable to community members and were consistent with community practices and beliefs.
Abstract Introduction The Streamlined Antiretroviral Therapy Initiation Strategy (START‐ART) study found that a theory‐based intervention using opinion leaders to inform and coach health care providers about the risks of treatment delay, provision of point of care (POC) CD4 testing machines (PIMA) and reputational incentives, led to rapid rise in ART initiation. We used qualitative research methods to explore mechanisms of provider behaviour change. Methods We conducted in‐depth interviews (IDIs) with 24 health care providers and nine study staff to understand perceptions, attitudes and the context of changes in ART initiation practices. Analyses were informed by the Theoretical Domains Framework. Results Rapid dissemination of new practices was enabled in the environmental context of an existing relationship based on communication, implementation and accountability between Makerere University Joint AIDS Program (MJAP), a Ugandan University‐affiliated organization that provided technical oversight for HIV service delivery at the health facilities where the intervention was implemented, and a network of health facilities operated by the Uganda Ministry of Health. Coaching carried out by field coordinators from MJAP strengthened influence and informal accountability for carrying out the intervention. Frontline health workers held a pre‐existing strong sense of professional identity . They were proud of attainment of new knowledge and skills and gratified by providing what they perceived to be higher quality care. Peer counsellors , who were not explicitly targeted in the intervention design, effectively substituted some functions of health care providers; as role models for successful ART uptake, they played a crucial role in creating demand for rapid ART initiation through interactions with patients. Point of care (POC) CD4 testing enabled immediate action and relieved providers from frustrations of lost or delayed laboratory results, and led to higher patient satisfaction (due to reduced costs because of ability to initiate ART right away, requiring fewer return trips to clinic). Conclusions Qualitative data revealed that a multicomponent intervention to change provider behaviour succeeded in the context of strong institutional and individual relationships between a University‐affiliated organization, government facilities, and peer health workers (who acted as a crucial link between stakeholders) and the community. Fostering stable institutional relationships between institutional actors (non‐governmental organization (NGOs) and ministry‐operated facilities) as well as between facilities and the community (through peer health workers) can enhance uptake of innovations targeting the HIV cascade in similar clinical settings.
We interviewed California county health agency staff and administered a 58-county survey in 2002 and 2004 to inventory programs designed to improve access to care for the uninsured, and to assess county ability to meet the needs of California's uninsured during slow economic periods. Most counties have established means to connect people to existing public insurance programs and services have been expanded. Growth in new health care insurance programs for children and modest growth for adults are apparent. Counties pursue funding opportunities by a variety of strategies (e.g., leveraging of existing funding to secure new funds such as federal Healthy Community Access Program (HCAP) grants). While counties vary in their resources, political will, and barriers to care, they share a strong commitment to access to care. The implications of local efforts for state and federal policymaking are significant. In the absence of federal or state reform, county initiatives, particularly children's coverage expansions, may coalesce into state-level reform. Second, the state may move closer to access to health care for all as it recognizes the complementarity of county programs.
Resources devoted to combating the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) have increased dramatically since 2005 (Dieleman and others 2014). However, the rate of increase has slowed in recent years, even though the commitment required to serve all of those in need and to reverse the epidemic has not been reached (Schwartlander and others 2011; UNAIDS 2013, 2014; WHO 2013). In addition, new recommendations to start treatment earlier in the disease course mean that more resources will be needed than previously estimated. Many of the countries with the highest prevalence of HIV/AIDS have low incomes and carry a heavy burden of other diseases, and it is particularly important to deploy resources judiciously. Finally, efficiency is an even greater imperative in the current era of transition away from funding dominated by international donor aid toward a funding model in which the national governments in affected countries bear a larger portion of the costs; this is especially so since, by some metrics, national governments are failing to increase their own contributions rapidly enough (Resch, Ryckman, and Hecht 2015). Ensuring that available resources are allocated to the most-cost-effective activities is essential to pursuing the aspirational “Getting to Zero” goals of the Joint United Nations Programme on HIV/AIDS (UNAIDS): zero new infections, zero AIDS-related deaths, and zero discrimination. Similar challenges also face global efforts to control tuberculosis and malaria—resources fall short of ambitious prevention and treatment targets.Various effectiveness, cost-effectiveness, and resource allocation models have been developed to evaluate the costs and outcomes of the choices facing HIV/AIDS policy makers at national and international levels. This chapter presents an overview—including features, uses, and limitations—of the small subset of models that explores the allocation of HIV/AIDS resources across many intervention options and purposes. It does not assess the more numerous models that analyze the cost-effectiveness of one or a few interventions for one purpose. Accordingly, it assesses the set of software tools that portray a wide range of interventions and combinations of interventions in different settings with the goal of providing broad guidance for improved resource allocation.
