Health, Poverty, and Surgery in the US and Around the World

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Health, Poverty, and Surgery in the US and Around the World

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Title: Health, Poverty, and Surgery in the US and Around the World
Author: Shrime, Mark G. ORCID  0000-0002-3546-9867
Citation: Shrime, Mark G. 2015. Health, Poverty, and Surgery in the US and Around the World. Doctoral dissertation, Harvard University, Graduate School of Arts & Sciences.
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Abstract: Health improvement and financial ruin are often inexorably linked.
Nearly 30% of the global burden of disease is surgical [1], and over 30 million annual cases of financial ruin are attributable to accessing surgery [2]. In resource-poor countries, where 70% of all healthcare spending is out-of-pocket [3], catastrophic expenditure for medical care is extremely common [4-6]. In the United States, even those with health insurance face financial catastrophe: nearly two-thirds of bankruptcy is medical, and fully 75% of medically bankrupt individuals were insured at the time of their catastrophic medical bill [7]. Financial ruin is most pronounced among the global poor, among patients with life-threatening conditions, and, increasingly, among the elderly [2, 8-10].
As a result, although the World Health Organization [11], the United Nations [12], and the World Bank [13] have all called for financial risk protection in healthcare, medical impoverishment persists, sometimes forcing individuals into a choice between physical health and financial health.
Some choose the former and are willing to incur financial ruin to get care: they sell their assets, borrow, decrease consumption, or, catastrophically, face impoverishment in the pursuit of health [4-6, 14-28]. Others respond to a risk of poverty by not complying with physician recommendations, by seeking alternate providers, or by forgoing care altogether [29-34]. In patients with serious conditions, these choices can be lethal [32, 35].
In the US, national health policy has consistently focused on decreasing out-of-pocket medical costs as a mechanism for health improvement—and not always successfully: two years after the initiation of the Oregon Medicaid expansion, for example, health outcomes had not changed dramatically [36]. Globally, policies to improve access to surgical care either mirror this demand-side focus on out-of-pocket cost reduction or address the supply-side dearth of surgical providers through policies such as task shifting [37-39].

The goal of this dissertation, then, is to examine the effects of these policies and platforms for global surgical delivery on health, on impoverishment, and on inequity, and to determine how individuals value tradeoffs among these outcomes.
Chapter 1 investigates the role of government policies for increasing surgical access in public hospitals. This extended cost-effectiveness analysis utilizes publicly available data from Ethiopia to evaluate the health, financial, and equity impacts of nine essential surgical procedures on rural patients. Five policies addressing supply- and demand-side barriers to surgical access are examined: 1) universal public financing (UPF), 2) task shifting (TS), 3) UPF with the addition of vouchers (V) to address the nonmedical costs of care, 4) UPF + TS, and 5) UPF + TS + V. I find that, while all policies are likely to improve health, a tradeoff exists: TS averts deaths most dramatically, but does so at the cost of a large increase in financial catastrophe. UPF is more financially risk protective, but has a much smaller impact on health. Only policies that include vouchers for the non-medical costs of accessing care are found to provide an equitable distribution of benefits; the remaining policies continue to impoverish the poor.
Chapter 2 compares surgical delivery by charitable organizations with the governmental policies examined in Chapter 1. Using an agent-based model of cancer care in Uganda, the three common charitable platforms for surgical delivery—two-week “mission trips”, mobile surgical units, and free-standing specialty hospitals—are evaluated against combinations of UPF, TS, and V. In addition to health and catastrophic expenditure, two novel metrics are included to 1) incorporate the familial financial impact of a lack of access and 2) formalize the equitable distribution of benefits into a concentration index. I find that mobile surgical delivery platforms by non-governmental organizations can provide health and financial benefits equitably and efficiently and that they perform well when compared to health-system-strengthening policies. Other charitable platforms are equitable but are not efficient when compared with government policies. The results of this analysis also confirm the finding from Chapter 1 that equitable delivery platforms must address the non-medical costs associated with getting to care.
Chapter 3 tests the hypothesis that, in the setting of lethal disease, individuals value cure at all costs. A discrete choice experiment is undertaken in a nationally representative US sample of 2359 individuals. Respondents are asked to choose between two hypothetical treatments for a lethal disease, differing only in their chance of cure and their risk of bankruptcy. I find that the resulting indifference curve is multiplicative, and that Americans are less willing to shoulder high risks of bankruptcy to increase their probability of cure than has been previously assumed. Subgroup and sensitivity analyses do not alter this relationship, although, in some groups, the difference in preference between bankruptcy protection and cure is not statistically significant. In no subgroup, however, do I find evidence a significant preference for cure at any cost in the American population.
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