Legal status is an important social determinant of health. Immigration enforcement policies may be an important contributor to health disparities in the form of interior border checkpoints (IBCs). These checkpoints may prevent immigrants and their families from seeking needed medical care. Currently, we do not know how these barriers are perceived by the public. We administered a survey of 6,178 respondents from 13 November to 19 November of 2023 that contained a survey experiment to assess public attitudes on the issue. Respondents were generally not supportive of detaining individuals at IBCs or medical facilities for emergencies regardless of characteristics of the care-seeking individual. A majority was supportive of detention when medical treatment was complete. Respondents were generally more sympathetic towards children and pregnant women. Partisanship and sympathy expressed towards immigrants influenced attitudes towards detention. Findings based on race and ethnicity showed inconsistencies. A majority of Americans did not believe that IBCs should impede undocumented immigrants from accessing medical care, especially in emergency situations and for children and pregnant women. Our findings indicate that there is broad public support for expanding existing policies to allow for undocumented individuals to pass through IBCs to access medical care.

Therapeutic positioning reports (IPTs, Spanish acronym) are a crucial tool for informing funding and pricing decisions for drugs in the Spanish healthcare system. In 2020, for the first time the inclusion of economic evaluations (EEs) was explicitly set as a primary objective in a new Action Plan aimed at consolidating IPTs. This paper seeks to examine the uptake of EE into IPTs and to compare the methods and techniques employed in the EEs conducted during the two-year pilot phase following the reform, i.e., from June 2021 to July 2023. During this period, a total of 181 IPTs were published, with 19 (10.5%) incorporating an EE section. However, out of these 19 identified IPTs, six did not actually conduct a de novo EE, and four only performed a drug cost minimisation analysis. Six IPTs conducted EE analyses following international methodological standards. Based on this review, we observe that the percentage of IPTs incorporating EEs had remained low and exhibited significant heterogeneity. The experience of these two years must be translated into lessons that can serve to reinforce the evaluation of the efficiency of medicines in Spain in the coming years.

Prior to the No Surprises Act (NSA), numerous states passed laws protecting patients from surprise medical bills from out-of-network (OON) hospital-based physicians supporting elective treatment in in-network hospitals. Even in non-emergency situations, patients have little ability to choose physicians such as anaesthesiologists, pathologists or radiologists. Using a comprehensive, multi-payer claims database, we estimated the effect of these laws on hospital-based physician reimbursement, charges, network participation and potential surprise billing episodes. Overall, the state laws were associated with a reduction in anaesthesiology prices and charges, but an increase in pathology and radiology prices. The price effects for each state exhibit substantial heterogeneity. California and New Jersey experienced increases in network participation by anaesthesiologists and pathologists and reductions in potential surprise billing episodes, but, overall, we find little evidence of changes in network participation across all of the states implementing surprise billing laws. Our results suggest that the effects of the NSA may vary across states.

Although the fair financing report, ‘Open and Inclusive: Fair Processes for Financing Universal Health Coverage’, has many sage things to say about democratic deliberative processes, its title belies its content: the report does not offer any assessment of processes for financing universal health coverage. What it does instead is scrutinise processes for deciding how to finance universal health coverage without any linkage to substantive questions concerning financing, and, moreover, the discussion is not narrowly focused on fairness.

Private equity (PE) firms play an increasingly important role in healthcare. Yet, existing research remains uneven, mostly focused on the United States and on certain sectors such as nursing homes. Some geographical areas and health specialties remain under-explored. This brief paper outlines a research agenda focusing on three key issues: (1) PE's significance and (2) business strategies in healthcare, and (3) PE's impacts on health and healthcare. The paper uses primary care in Ireland as an example. The proposed research agenda should improve our understanding of the nature of PE in healthcare and serve as a basis for policy-makers to explore appropriate and effective regulation of PE to reduce its negative impacts if and when they exist.

The policy-making process for health financing in most places lacks equity, failing to adequately consider the voices of ordinary citizens, residents, and especially those facing significant disadvantage. Procedural fairness is about addressing this imbalance, which requires a recalibration of power dynamics, ensuring that decision-making incorporates a more diverse range of perspectives. In this comment, we highlight the important contributions made by the report ‘Open and inclusive: Fair processes for financing universal health coverage’ in furthering the understanding and importance of procedural fairness in health financing decision-making especially as it relates to the three sub-functions of financing – revenue raising, pooling, and purchasing. We also argue for the importance of conceptual clarity – especially as to the added value of procedural fairness vis-à-vis accountability – and critically review the proposed framework for procedural fairness, emphasising the role of voice as the linchpin to advancing equity in influence.

In many European countries, semi-autonomous agencies have been created in health policy to safeguard general public interests. In executing their tasks, these agencies need to deal with conflicting expectations. Particularly avoiding the risk of regulatory capture and aligning with parent ministries are frequently studied challenges, even more so when complex issues such as scarcity are at stake. In this paper, we use q-methodology to provide a thorough overview of the debate regarding the role of an important agency in the Dutch healthcare system; the National Health Care Institute (Zorginstituut Nederland). We conducted 41 q-interviews with agency employees, evaluators, regulatees, ministry employees, health policy experts, members of its advisory committees, and peer agencies. We identify three viewpoints on what the agency should focus on. These are on societally relevant issues, strict package management, and efficient organisation of care. In doing so, our study shows how agencies are pulled in different directions by conflicting expectations. We show that this can be problematic because it complicates a clear role of the agency that allows addressing such issues. We thereby contribute to theories on agencies' complex relations with their external environment such as regulatory capture, tripartism, reflexive regulation, legal boundaries, and stewardship theory.

The impact of health technologies may extend beyond the patient and affect the health of people in their network, like their informal carers. The National Institute for Health and Care Excellence (NICE) methods guide explicitly allows the inclusion of health-related quality of life (HRQoL) effects on carers in economic evaluations when these effects are substantial, but the proportion of NICE appraisals that includes carer HRQoL remains small. This paper discusses when inclusion of carer HRQoL is justified, how inclusion can be substantiated, and how carer HRQoL can be measured and included in health economic models. Inclusion of HRQoL in economic evaluations can best be substantiated by data collected in (carers for) patients eligible for receiving the intervention. To facilitate combining patient and carer utilities on the benefit side of economic evaluations, using EQ-5D to measure impacts on carers seems the most successful strategy in the UK context. Alternatives to primary data collection of EQ-5D include vignette studies, using existing values, and mapping algorithms. Carer HRQoL was most often incorporated in economic models in NICE appraisals by employing (dis)utilities as a function of the patient's health state or disease severity. For consistency and comparability, economic evaluations including carer HRQoL should present analyses with and without carer HRQoL.

We use Benford's law to examine the non-random elements of health care costs. We find that as health care expenditures increase, the conformity to the expected distribution of naturally occurring numbers worsens, indicating a tendency towards inefficient treatment. Government insurers follow Benford's law better than private insurers indicating more efficient treatment. Surprisingly, self-insured patients suffer the most from non-clinical cost factors. We suggest that cost saving efforts to reduce non-clinical expenses should be focused on more severe, costly encounters. Doing so focuses cost reduction efforts on less than 10% of encounters that constitute over 70% of dollars spent on health care treatment.

In the three years since the law on adult deceased organ donation consent in England changed to include an opt-out system, there has been no discernible change to donation rates. The lack of a positive impact on donation rates was predicted by many of those who took part in debates before and during the passage of the Bill through Parliament. This invites the question as to why England moved to an opt-out system for organ donation despite equivocal evidence of likely benefit and opposition from expert health professional organisations. To address this question qualitative analyses of Parliamentary debates on organ donation was undertaken. This revealed a shift from a dominant position, which gave primacy to the evidence of likely effects, towards a more normative position where a deemed consent option was viewed as the ‘correct thing to do’ and the limited and conflicting evidence viewed in a positive light. By 2017, following Wales's move to an opt-out system, together with continued lobbying for similar changes for England by professional and patient groups, alongside sustained public popularity for organ donation, the balance of opinion had shifted towards a system where deemed consent would become the default position for most English adults

As the world comes together through the WHO design and consultation process on a new medical counter-measures platform, we propose an enhanced APT-A (Access to Pandemic Tools Accelerator) that builds on the previous architecture but includes two new pillars – one for economic assistance and another to combat structural inequalities for future pandemic preparedness and response. As part of the APT-A, and in light of the Independent Panel on Pandemic Preparation & Response's call for an enhanced end-to-end platform for access to essential health technologies, we propose a new mechanism that we call the Pandemic Open Technology Access Accelerator (POTAX) that can be implemented through the medical countermeasures platform and the pandemic accord currently under negotiation through the World Health Assembly and supported by the High-Level Meeting review on Pandemic Prevention, Preparedness, and Response at the United Nations. This mechanism will provide (1) conditional financing for new vaccines and other essential health technologies requiring companies to vest licenses in POTAX and pool intellectual property and other data necessary to allow equitable access to the resulting technologies. It will also (2) support collective procurement as well as measures to ensure equitable distribution and uptake of these technologies.

Many governments employed mandates for COVID-19 vaccines, imposing consequences upon unvaccinated people. Attitudes towards these policies have generally been positive, but little is known about how discourses around them changed as the characteristics of the disease and the vaccinations evolved. Western Australia (WA) employed sweeping COVID-19 vaccine mandates for employment and public spaces whilst the state was closed off from the rest of the country and world, and mostly with no COVID-19 in the community. This article analyses WA public attitudes during the mandate policy lifecycle from speculative to real. Qualitative interview data from 151 adults were analysed in NVivo 20 via a novel chronological analysis anchored in key policy phases: no vaccine mandates, key worker vaccine mandates, vaccine mandates covering 75% of the workforce and public space mandates. Participants justified mandates as essential for border reopening and, less frequently, for goals such as protecting the health system. However, public discourse focusing on ‘getting coverage rates up’ may prove counter-productive for building support for vaccination; governments should reinforce end goals in public messaging (reducing suffering and saving lives) because such messaging is likely to be more meaningful to vaccination behaviour in the longer term.

This article identifies issues relating to the use of genetics and genomics in risk-rated insurance that may challenge existing regulatory models in the UK and elsewhere. We discuss three core issues: (1) As genomic testing advances, and results are increasingly relevant to guide healthcare across an individual's lifetime, the distinction between diagnostic and predictive testing that the current UK insurance code relies on becomes increasingly blurred. (2) The emerging category of pharmacogenetic tests that are predictive only in the context of a specific prescribing moment. (3) The increasing availability and affordability of polygenic scores that are neither clearly diagnostic nor highly predictive, but which nonetheless might have incremental value for risk-rated insurance underwriting beyond conventional factors. We suggest a deliberative approach is required to establish when and how genetic information can be used in risk-rated insurance.

Health systems’ insurance/funding can be organised in several ways. Some countries have adopted systems with a mixture of public–private involvement (e.g. Australia, Chile, Ireland, South Africa, New Zealand) which creates two-tier health systems, allowing consumers (groups) to have preferential access to the basic standard of care (e.g. skipping waiting times). The degree to which efficiency and equity are achieved in these types of systems is questioned. In this paper, we consider integration of the two tiers by means of a managed competition model, which underpins Social Health Insurance (SHI) systems. We elaborate a two-part conceptual framework, where, first, we review and update the existing pre-requisites for the model of managed competition to fit a broader definition of health systems, and second, we typologise possible roadmaps to achieve that model in terms of the insurance function, and focus on the consequences on providers and governance/stewardship.

The consequences of legal access to medical marijuana for individuals' well-being are controversially assessed. We contribute to the discussion by evaluating the impact of the introduction of medical marijuana laws across US states on self-reported mental health considering different motives for cannabis consumption. Our analysis is based on BRFSS survey data from close to eight million respondents between 1993 and 2018 that we combine with information from the NSDUH to estimate individual consumption propensities. We find that eased access to marijuana through medical marijuana laws reduce the reported number of days with poor mental health for individuals with a high propensity to consume marijuana for medical purposes and for those individuals who likely suffer from frequent pain.

This paper explores the keywords of ‘National’, ‘Health’ and Service’ in the road to the NHS in 1948. It uses a form of Qualitative Content Analysis to analyse key documents in the period leading to the ‘Appointed Day’ when the NHS was created in 1948. In terms of ‘national’, most documents favoured Local Authorities, with ‘National’ coming rather late in the day. For ‘health’, most of the documents ‘talk’ of a broad or ‘positive’ health, but they lack any specific details, and seem to focus on a narrower curative medical service. Finally, most proposals relating to ‘service’ are based on insurance and a ‘90% service’, with the free and universal (100%) service arriving rather late in the period. Clearly, the three keywords could be combined in many ways, resulting in many possible types of NHS. However, bringing them together suggests that it was probably only with Beveridge onwards that the three keywords of national, health and service (citizenship) combined to form Bevan's NHS.

The allocation of resources is a crucial part of political decision-making in healthcare, but explicit priorities are rarely set when resources are distributed. Two areas that have received some attention in research about legitimacy and priority-setting decisions in healthcare are the role of technical expert agencies as mediating institutions and the role of elected politicians. This paper investigates a political priority-setting advisory committee within a regional authority in Sweden. The aim is to explore how a political body can serve as a mediating institution for priority-setting in healthcare by disentangling the arrangements of its work in terms of what role it performs in the organisation and what it should do. The findings illustrate that promoting the notion of explicit priority-setting and the political aspects inherent in priority-setting in political healthcare management can contribute to consolidating political governance and leadership. There is, however, a complex tension between stability and conflicting values which has implications for the role of politicians as citizens' democratic representatives. This paper enhances our understanding of the role of mediating institutions and political properties of healthcare priority-setting, as well as our understanding of political and democratic healthcare governance in local self-government.

This paper considers whether and how managed competition arrangements could be introduced into the Aotearoa health and disability system. The paper describes the key features of the system, including new organisational arrangements established from 1 July 2022. It discusses major reforms and managed competition plans that were developed in the 1990s, with the managed competition plans abandoned fairly early on, as a result of major issues with the reforms that had been implemented and with problems in designing a fair payment system for competing health plans. The paper goes on to argue that the development of capitated, risk-bearing and competing Primary Health Organisations set up in the 2000s should be considered in terms of managed competition, and the paper points to the issues that have arisen in Aotearoa due to a lack of regulations that would have better supported the better achievement of effectiveness, efficiency, and equity goals over the past 20 years. Finally, the paper also looks ahead to whether and how managed competition might again be considered in Aotearoa and the extent to which the system currently includes key pre-conditions to support such arrangements.

The management implications of pricing healthcare services, especially hospitals, have received insufficient scholarly attention. Additionally, disciplinary overlaps have led to scattered academic efforts in this domain. This study performs a thematic synthesis of the literature and applies retrospective analysis to hospital service pricing articles to address these issues. The study's inputs were sourced from well-known online repositories, using a structured search string and PRISMA flow chart to select the pertinent documents. Our thematic analysis of pricing literature encompasses: (a) comprehension of hospital service pricing nature; (b) pricing objectives, strategies and practices differentiation; (c) presentation of factors impacting hospital service pricing. We observe that hospital pricing is an intricate and unclear matter. The terms ‘pricing strategies’ and ‘pricing practices’ are often used interchangeably in academic literature. Hospital service pricing is influenced by costs, demand and supply factors, market structure, pricing regulation and third-party reimbursements. The study's findings provide policy implications for service pricing in hospitals, in addition to suggesting avenues for future research on hospital pricing.