Victor Rodwin

The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States

The French health system combines universal coverage with a public-private mix of hospital and ambulatory care and a higher volume of service provision than in the United States. Although the system is far from perfect, its indicators of health status and consumer satisfaction are high; its expenditures, as a share of gross domestic product, are far lower than in the United States; and patients have an extraordinary degree of choice among providers. Lessons for the United States include the importance of governments role in providing a statutory framework for universal health insurance; recognition that piecemeal reform can broaden a partial program (like Medicare) to cover, eventually, the entire population; and understanding that universal coverage can be achieved without excluding private insurers from the supplementary insurance market.

Gender and the Treatment of Heart Disease in Older Persons in the United States, France, and England: A Comparative, Population-Based View of a Clinical Phenomenon

BACKGROUND Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities. OBJECTIVE This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London. METHODS This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values. RESULTS Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease. CONCLUSIONS A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

The world cities project: Rationale, organization, and design for comparison of megacity health systems

This article provides an overview of the World Cities Project (WCP), our rationale for it, our framework for comparative analysis, and an overview of current studies in progress. The WCP uses New York, London, Paris, and Tokyo as a laboratory in which to study urban health, particularly the evolution and current organization of public health infrastructure, as well as the health status and quality of life in these cities. Comparing world cities in wealthier nations is important because of (1) global trends in urbanization, emerging health risks, and population aging; (2) the dominant influence of these cities on “megacities” of developing nations; and (3) the existence of data and scholarship about these world cities, which provides a foundation for comparing their health systems and health. We argue that, in contrast to nation-states, world cities provide opportunities for more refined comparisons and cross-national learning. To provide a framework for WCP, we define an urban core for each city and examine the similarities and differences among them. Our current studies shed light on inequalities in health care use and health status, the importance of neighborhoods in protecting population health, and quality of life in diverse urban communities.

The Once and Future Health System in the Former Yugoslavia: Myths and Realities

This paper debunks three widely believed myths about the former Yugoslavias health care system: that it was characterized by: (1) social ownership of “self-managing” provider organizations; (2) a commitment to primary health care; and (3) a faith in what might be called the “march of progress”—the health systems continuous expansion and improvement. In contrast to this picture, we present an alternative view and conclude with a word of caution for American consultants and health care reformers in Eastern European countries and newly independent states: If universal health coverage is to be maintained, beware of reforms that do no more than substitute private for public organizational forms.

Infant mortality and income in 4 world cities: New York, London, Paris, and Tokyo.

OBJECTIVES We investigated the association between average income or deprivation and infant mortality rate across neighborhoods of 4 world cities. METHODS Using a maximum likelihood negative binomial regression model that controls for births, we analyzed data for 1988-1992 and 1993-1997. RESULTS In Manhattan, for both periods, we found an association (.05% significance level) between income and infant mortality. In Tokyo, for both periods, and in Paris and London for period 1, we found none (5% significance level). For period 2, the association just missed statistical significance for Paris, whereas for London it was significant (5% level). CONCLUSIONS In stark contrast to Tokyo, Paris, and London, the association of income and infant mortality rate was strongly evident in Manhattan.

In the heat of the summer : lessons from the heat waves in Paris

Climate change and human health are intertwined.1 The heat waves in Chicago, in 1995, and in Paris, in 2003, followed by Hurricane Katrina’s destruction of New Orleans, raised awareness of the risks faced by vulnerable older people. Many cities have responded by announcing emergency preparedness plans; some of these plans have already been tested. Last summer, from July 27 to August 5, New York City suffered a mild heat wave with temperatures reaching 100°F. Paris, as well, was hit by another heat wave from July 17 to July 29, with maximum temperatures reaching 104°F, which was considerably milder than in 2003 when they often exceeded 110°F. In New York, there were 100 “excess deaths,” an increase of 8% over past trends.2 In Paris, the number of excess deaths in 2006 (42), also an increase of 8%, was considerably lower than the 1,294 deaths registered in 2003—an increase of 190% compared to the preceding three-year average. Given existing surveillance capacity, it is impossible to know whether the reduction in excess deaths in Paris was due, partly, to its enhanced preparedness or whether it reflects no more than the effects of a far milder heat wave. Nevertheless, the milder heat wave of 2006 does provide an opportunity to examine the actual implementation of the heat wave preparedness plan. In light of ongoing efforts to develop such plans in cities worldwide and completed studies on the effects of the 2003 heat wave in Paris, what may be learned to promote urban health and improve understanding of the factors that put vulnerable older people at greatest risk?

American exceptionalism in the health sector: the advantages of "backwardness" in learning from abroad.

*Associate Professor, and Associate Director, Advanced Management Program for Clinicians (AMPC), Graduate School of Public Administration, New York University, New York, N.Y. The United States is the only industrially advanced nation with over 15 percent of its population uninsured for health care services. 1 This aspect of American health policy has earned us a reputation of &dquo;backwardness&dquo; ; for both Western Europe and Canada have systems of universal entitlement to health care.

Factors affecting the introduction of new vaccines to poor nations: a comparative study of the Haemophilus influenzae type B and hepatitis B vaccines.

Background A major effort to introduce new vaccines into poor nations of the world was initiated in recent years with the help of the GAVI alliance. The first vaccines introduced have been the Haemophilus influenzae type B (Hib) and the hepatitis B (Hep B) vaccines. The introduction of these vaccines during the first phase of GAVIs operations demonstrated considerable variability. We set out to study the factors affecting the introduction of these vaccines. The African Region (AFRO), where new vaccines were introduced to a substantial number of countries during the first phase of GAVIs funding, was selected for this study. Methodology/Principal Findings GAVI-eligible AFRO countries with a population of 0.5 million or more were included in the study. Countries were analyzed and compared for new vaccine introduction, healthcare indicators, financial indicators related to healthcare and country-level Governance Indicators, using One Way ANOVA, correlation analysis and Qualitative Comparative Analysis (QCA). Introduction of new vaccines into AFRO nations was associated primarily with high country-level Governance Indicator scores. The use of individual Governance Indicator scores, as well as a combined Governance Indicator score we developed, demonstrated similar results. Conclusions/Significance Our study results indicate that good country-level governance is an imperative pre-requisite for the successful early introduction of new vaccines into poor African nations. Enhanced support measures may be required to effectively introduce new vaccines to countries with low governance scores. The combined governance score we developed may thus constitute a useful tool for helping philanthropic organizations make decisions regarding the type of support needed by different countries to achieve success.

ON HEALTH POLICY AND MANAGEMENT (HPAM): MIND THE THEORY-POLICY-PRACTICE GAP

We argue that the field of Health Policy and Management (HPAM) ought to confront the gap between theory, policy, and practice. Although there are perennial efforts to reform healthcare systems, the conceptual barriers are considerable and reflect the theory-policy-practice gap. We highlight four dimensions of the gap: 1) the dominance of microeconomic thinking in health policy analysis and design; 2) the lack of learning from management theory and comparative case studies; 3) the separation of HPAM from the rank and file of healthcare; and 4) the failure to expose medical students to issues of HPAM. We conclude with suggestions for rethinking the field of HPAM by embracing broader perspectives, e.g. ethics, urban health, systems analysis and cross-national analyses of healthcare systems.

A new approach to the comparative analysis of health systems: invasive treatment for heart disease in the US, France, and their two world cities

Cross-national comparisons that assess dimensions of health system performance indicate that the US provides higher rates of revascularization procedures than France and other developed nations, but we believe these findings are misleading. In this paper, we compare the use of these procedures in the US, France and their two world cities, Manhattan and Paris. In doing so, we address a number of limitations associated with existing cross-national comparisons of heart disease treatment. After adjusting for the prevalence of disease in these nations and cities, we found that residents of France aged 45-64 years receive more revascularization procedures than residents of the US and that Parisians receive more revascularizations than residents of Manhattan. Older residents 65 years and over (65+) in the US receive more of these procedures than their French counterparts, but the differences are not nearly as great as previous studies suggest. Moreover, our data on Manhattan and Paris where the population and level of health resources are more comparable, indicate that older Parisians obtain more revascularization procedures than older Manhattanites. Finally, we found that the use of revascularization procedures is significantly lower in Manhattan among persons without private health insurance and among racial and ethnic minorities.