People's positions regarding social security's health insurance programs: The case of Romania

BackgroundIn Romania, the passage from a culture in which healthcare were freely available to a culture in which people must contribute financially, at least in part, has generated controversies among the population. We examined and mapped the views of people living in Romania regarding social security's health insurance programs.MethodsA convenience sample of 271 adults aged 18–80 who lived in big cities in Romania or in the rural areas around these cities were presented with realistic vignettes that depicted a health insurance program and asked to rate its goodness. The vignettes were created by combining orthogonally the levels of five factors: amount of employers’ contribution to the program, amount of workers’ contribution, extent of coverage of ordinary medical and dental care, extent of coverage of chronic or severe illness, and identity of health insurance recipients.ResultsFive qualitatively different positions were found. They were called Private insurance (8%), Health insurance only for contributors (14%), Health insurance for contributors and for everyone with severe or chronic illness (12%), Health insurance for everyone (29%), and Any insurance program is better than nothing (37%).ConclusionOverall, most participants (78%) favored a health insurance program that would protect all citizens in case of severe or chronic illness or injury, and 66% favored the protection of all citizens in all cases.     

Enacting Actuarial Fairness in Insurance: From Fair Discrimination to Behaviour-based Fairness

ABSTRACT

In line with developments in the personalisation of risk, the idea that insurance products should above all be ‘fair’ to the policyholders is increasingly voiced by commentators. The performativity thesis in Science and Technology Studies usually used to study economic markets can be used to investigate different enactments of ‘actuarial fairness’ in insurance practice. Actuarial fairness functions as a technical economic concept and was coined by the neoclassical micro-economist Kenneth Arrow (1921–2017). Faced with anti-discrimination legislation, the insurance industry has, since the 1980s, advanced the principle of actuarial fairness to legitimise their medico-actuarial technologies to discriminate between risk groups. In the absence of this actuarial fairness, it is assumed that dynamics of adverse selection—derived from neoclassical assumptions about economic actors— will result in the bankruptcy of insurance providers. The paradigmatic case of Fairzekering, a showcase of contemporary behaviour-based personalisation in car insurance, demonstrates an important shift in how actuarial fairness is enacted through behaviour-based calculative devices. Here, policyholders are enacted as being personally in control of their driving style while an interactive discount-infrastructure is set up to provide real-time feedback to incentivize policyholders towards ‘good behaviour.’ This enactment of behaviour-based fairness simultaneously implies a shift in the enactment of the economic actors involved, constitutive of the making of new economic ideas in behavioural economics.     

The Needle in the Haystack

Summary

Despite the significant damages in sexual abuse cases, the plaintiff's ability to collect the money awarded in settlement or judgment is often precluded by the limited financial resources of the defendant(s). In this chapter, practicing attorney Julian Hubbard introduces the basics of individual and corporate insurance coverage and reviews the development of very limited coverage in sexual abuse cases in statutory and case law. While direct coverage for sexual abuse injuries is as rare as a “needle in a haystack,” indirect coverage can be found in some cases, especially those in which the acts of negligent individuals other than the perpetrator facilitated the abuse and thus the plaintiff's injuries. After an overview of relevant insurance issues and law, Mr. Hubbard delineates a practical model for research and legal strategies to ensure reaching any available insurance coverage, and explores the benefits and drawbacks of drawing on administrative resources to help pay for survivors' medical and mental health care.     

Understanding Transference and Countertransference

Abstract

Professional misconduct-especially misconduct involving client-worker boundary violationsgenerates serious costs for clinical social workers. It harms the very clients we aim to help; it frequently tarnishes the reputation of not only the individual social worker involved but also the face of the entire profession; and, it adds significantly to the overall costs of malpractice insurance. This paper defines the scope of the problem and provides support for understanding transference and countertransference as important contributors to prevention.     

Introduction

Abstract

Managed health care policy has created dramatic changes in current clinical practice, and all too frequently, impacts the overall treatment plan. Clinicians making referrals for emergency hospitalizations can no longer rely on an in-patient, safe, holding environment. Rather the hospital's relationship and stance with managed care insurance providers determines the length of the hospitalization and the case management plan for patients, instead of the patient's need.     

Does age matter? Examining age-dependent differences in at-fault collisions after attending a refresher course for older drivers

The “Driver 65+” course is a voluntary refresher course offered to all drivers aged 65 years or older in Norway. The current study estimated differences in at-fault motor vehicle collisions (MVCs) between older drivers who had attended in the course and older drivers who had not attended the course.MethodsTwo samples of drivers were selected from the database of an insurance company and were sent a questionnaire in the mail. The first sample consisted of 2039 car owners aged 70 years or older who had reported a collision to the insurance company during the last 24 months. The second sample consisted of 1569 drivers aged 70 or older who had not reported any collisions during the last 24 months.ResultsThe results indicated an age-dependent effect; drivers attending the course before 75 years of age had a significantly lower risk of being the at-fault driver in a multi-MVC than older drivers who did not attend the course.ConclusionThe results indicate that the refresher course had a beneficial effect on collision risk for drivers who attended the course before reaching 75 years of age. One possible explanation of this age-dependent effect is that a certain level of visual, cognitive, and motor functioning is needed to implement the strategies learned in the course. However, the design of the study makes it difficult to draw definite conclusions about the causal relationship between course attendance and later collision involvement.     

Chest reconstructive surgeries in transmasculine youth: Experience from one pediatric center

Background: For many trans males, having chest reconstruction is a very important part of the transitioning process. Guidelines from WPATH and the Endocrine Society suggest 16 to 18 years old as an acceptable age for this surgical intervention. In clinical practice, the decision depends on factors such as a person's desires, insurance coverage, and availability of local surgical experts. We present data about chest reconstructive surgeries in transgender youth from a Pediatric Gender Management (GeM) clinic.

Methods: For this retrospective, observational study, data were collected from GeM clinic patients seen from 10/1/2011 to 1/31/2017. All subjects consented or assented to being included in an IRB-approved clinical database.

Results: Of 210 patients from our clinic, 167 consented to being added to an institutional review board–approved database and followed prospectively. The average age at the initial visit was 15.2 years (range, 4.7–20.9). Among consenting subjects, 55 were trans females, 108 were trans males, and four identified as nonbinary. Fourteen subjects had chest reconstruction with the mean age being 17.2 years (range, 13.4–19.7); three subjects were under age 16. For five subjects, including the youngest one, insurance paid for the procedure. All participants but one were receiving testosterone treatment. Per the surgeons' preferences, testosterone was usually not temporarily stopped prior to the procedure. Six subjects had the procedure done locally; others sought surgical care out of the town, state, or country. All subjects were very satisfied with the aesthetics of the surgical outcome. The self-reported complication rate was low. Many more GeM clinic patients wish to have breast/chest surgery but lack of insurance coverage makes the surgery cost prohibitive.

Conclusion: For many trans males, chest reconstructive surgery is an integral part of the transition process. Patients' age at the time of surgical procedure varies greatly; some have chest surgery before age 16. In the United States, chest reconstruction surgery is usually not covered by insurance. Therefore, many patients seeking surgical care are forced to pay out of pocket.     

Individual,family, and societal dimensions of genetic discrimination: A case study analysis

Background. As the development and use of genetic tests have increased, so have concerns regarding the uses of genetic information. Genetic discrimination, the differential treatment of individuals based on real or perceived differences in their genomes, is a recently described form of discrimination. The range and significance of experiences associated with this form of discrimination are not yet well known and are investigated in this study. Methods. Individuals at-risk to develop a genetic condition and parents of children with specific genetic conditions were surveyed by questionnaire for reports of genetic discrimination. A total of 27,790 questionnaires were sent out by mail. Of 917 responses received, 206 were followed up with telephone interviews. The responses were analyzed regarding circumstances of the alleged discrimination, the institutions involved, issues relating to the redress of grievances, and strategies to avoid discrimination. Results. A number of institutions were reported to have engaged in genetic discrimination including health and life insurance companies, health care providers, blood banks, adoption agencies, the military, and schools. The alleged instances of discrimination were against individuals who were asymptomatic and sometimes impacted on other asymptomatic relatives. Few surveyed respondents knew of the existence of institutions such as state insurance commissions or the Medical Information Bureau, Inc., which may play roles in redress of grievances or correction of misinformation. Conclusions. Genetic discrimination is variable in form and cause and can have marked consequences for individuals experiencing discrimination and their relatives. The presence of abnormal genes in all individuals makes each person a potential victim of this type of discrimination. The increasing development and utilization of genetic tests will likely result in increased genetic discrimination in the absence of contravening measures. All authors contributed equally to this work. This work was supported by a grant from the U.S. Department of Energy and funding from the Department of Mental Retardation of the Commonwealth of Massachusetts.     

Stereotypes

Summary

This study investigated relations between Fiddler's esteem for the least preferred co-worker (LPC) measure, leader behavior, and group performance among 53 first-line supervisors of life insurance agents. The overall findings indicated that the relative amount of consideration given to subordinates increased with increased group performance. However, this general trend was particularly marked with respect to low LPC supervisors. It was concluded that LPC measures a triggered behavioral disposition reflecting the degree to which leaders are responsive to task-related feedback.     

How does education lead to healthier behaviours? Testing the mediational roles of perceived control,health literacy and social support

Abstract

Objectives: Educational attainment is increasingly recognised as a unique dimension of socioeconomic status (SES) and a powerful determinant of health behaviour—and thus physical health and mortality. However, very little is known about the specific pathways through which education influences these health behaviours. Design: The present study used a nationally representative US survey to test three potential psychosocial pathways (perceived control, health literacy and social support) through which education might influence intake of fruits and vegetables (FV), physical activity (PA) and sedentary behaviour (SB), controlling for other aspects of SES (income, health insurance status) and demographics (age, gender, race/ethnicity). Results: Both aspects of perceived control (locus of control, cancer fatalism) mediated the impact of education on FV and PA while only locus of control mediated the impact of education on SB. Further, only one aspect of health literacy (ability to understand recommendations) mediated education’s effect on any health behaviour (FV). Social support did not mediate any of the effects of education on health behaviors. Conclusion: Future work explicitly assessing and testing these mediational pathways is needed to better understand how education influences people’s health behaviours throughout their lives.     

Physical activity in employees with differing occupational stress and mental health profiles: A latent profile analysis

ObjectivesTo examine whether employees with differing occupational stress and mental health profiles differ in their self-reported levels of physical activity.DesignCross-sectional survey data.MethodThe sample consisted of 2660 Swedish health care workers and social insurance officers (85% women, M = 46.3 years). Latent profile analysis was performed to identify classes. Between-class-differences in physical activity were tested via χ²-tests and multinominal logistic regression analyses using sex, age, BMI, marital status, children at home, caregiving, and smoking as covariates.ResultsLatent profile analysis resulted in a six-profile solution. Two pairs of classes had equal stress levels, one pair with high stress, one pair with moderate stress. Within each pair, one group showed some resilience (i.e. only moderate mental health problems despite high stress or good mental health despite moderate stress), whereas the other did not. The other two classes were characterized by either low stress and good mental health or moderate-to-high stress and elevated mental health problems. Participants who were resilient to high or moderate stress were more active than participants of the corresponding non-resilient classes. Participants with low stress and good mental health reported the highest physical activity levels, participants with high stress and high mental health problems reported the lowest physical activity levels.ConclusionsThe findings suggest that physical activity is associated with resilience to occupational stress, and that beyond primary prevention efforts to make work less stressful regular physical activity should be a target variable for health professionals working in the occupational setting.     

Transgender and gender non-conforming adult preparedness for aging: Concerns for aging,and familiarity with and engagement in planning behaviors

Abstract

Background: Research on transgender and gender-nonconforming (TGNC) aging is limited. To date, most of the literature about TGNC aging has focused on discrimination (particularly in healthcare), violence and abuse, caregiving and family relations, and religiosity.

Aims: The purposes of this study were to: (a) document concerns about aging among TGNC adults, including concerns that are identity-specific; (b) examine preparation for aging and end of life (i.e., familiarity and planning) among TGNC adults; and (c) examine potential differences in familiarity and planning based on gender identity.

Methods: One hundred fifty-four individuals who currently or have ever identified as TGNC completed a national online survey assessing these constructs.

Results: TGNC individuals reported many concerns about aging, both gender identity-specific and not. The most common aging concern was losing the ability to care for themselves followed by having to go into a nursing home or assisted living facility. The age preparatory behaviors individuals were most commonly aware of included: life insurance, wills, organ donation, regular medical checkups, living wills, durable power of attorney for healthcare, and trusts. Gender-nonconforming individuals had significantly more familiarity with age preparatory behaviors than trans feminine individuals, but had lower levels of planning to engage in age preparatory behaviors than both trans masculine and trans feminine individuals.

Conclusion: The current findings highlight the need for providers to address age preparatory behaviors with TGNC individuals or provide referrals to support individuals in this planning.     

Psychoanalytic Perspectives Concerning the Impact of Managed Care on Psychotherapy

Abstract

The impact of managed care insurance coverage on the psychoanalytic situation is explored, using case material to show the particular ways transference and resistance may differ or not differ under this special circumstance. Managed care shapes typical areas of anxiety such as fees, schedules, frequency, and termination into riper opportunities for transference and resistance exploration. However, the so-called reality factor of an external influence easily disguises these potentialities. The analyst may unwittingly act out countertransference feelings using this “reality factor” as a rationale. While managed care does shift the nature of the therapeutic relationship, the emphasis on interpretation of transference and resistance remains at the forefront of technique.     

Life is Good

Abstract

The author inquires into the relation between the production of genetic knowledge on the one hand, and human autonomy and self-determination on the other. He does so by specifying the notions of “genetic test” and “human autonomy”; by discussing the epistemic status of genetic knowledge, given its importance for the clarification of its anthropological and ethical implications; and by inquiring into some ethical implications by investigating the conditions under which genetic knowledge of the individual may justifiably be established. This discussion shows that the autonomy-based right to self-determination as far as gene information is concerned, is fundamental. This has major implications, which the author identifies with regard to the difficult problem of the moral legitimacy of the use of genetic knowledge in the context of insurance policies.     

Rethinking Professional Ethics in the Cost-Sharing Era

Changes in healthcare financing increasingly rely upon patient cost-sharing to control escalating healthcare expenditures. These changes raise new challenges for physicians that are different from those that arose either under managed care or traditional indemnity insurance. Historically, there have been two distinct bases for arguing that physicians should not consider costs in their clinical decisions—an “aspirational ethic” that exhorts physicians to treat all patients the same regardless of their ability to pay, and an “agency ethic” that calls on physicians to be trustworthy advisors to their patients. In the setting of greater patient cost-sharing, physicians' aspiration and agency roles increasingly conflict. Satisfactorily navigating the new terrain of consumer-driven healthcare requires physicians to consider these two roles and how they can best be reconciled so as to maximize quality of care while respecting the heterogeneity of patients' financial resources and willingness to pay.     

Ask,Answer, and Announce: Three stages in perceiving and responding to discrimination

Discrimination towards members of low-status groups takes a variety of forms, and results in a variety of negative consequences for its victims. Furthermore, discrimination may influence its targets either directly (for instance, when housing discrimination makes insurance, mortgage rates, or rents higher for African Americans than for whites) or indirectly, that is via perceptions on the part of the stigmatised. In the latter case the outcomes are caused or amplified by perceptions on the part of the victim that he or she is the target of discrimination. This chapter focuses on current research concerning factors that influence the perception of discrimination and its indirect influence on individuals. We review work from our own lab as well as from the field more broadly, focusing on research that attempts to explain contextual and individual variability in how events that are potentially due to discrimination are initially perceived, subsequently interpreted, and then publicly reported or withheld.     

Psychoanalysis is becoming an impossible profession within the public welfare system in Sweden

Abstract

The preconditions for psychoanalytic practice within the Swedish public welfare system are analyzed in this article. Psychoanalysis remains a one-to-one treatment and relies on the analyst's capacity to use his or her own subjective response. The development of the psychoanalytic process is dependent on unconscious reality, making it impossible to work with a model that has a strict relation between diagnosis, treatment method, and result. Objectivity and the desire to predict treatment outcomes characterize the immanent logic in the complex system of laws and recommendations that affects most practices within the field of medicine. As a consequence of this development, psychoanalysis and psychodynamic therapy are marginalized, since our treatment methods are not adapted to the present industrialization and economization of the medical health sector, with the result that the preconditions for psychoanalytic training have changed dramatically. The exclusion of psychoanalysis from the national health insurance scheme is a demanding challenge at a time when the Swedish welfare model is undergoing fundamental changes.     

Disparities in access to family physicians among transgender people in Ontario,Canada

Background: Informed by the Gelberg-Andersen behavioral model for vulnerable populations, this study examined the prevalence of and factors associated with not having a family physician among transgender (trans) people in Ontario, Canada.

Methods: Data were drawn from a respondent-driven sampling (RDS) survey of trans Ontarians age 16 and above (n = 433) conducted between 2009 and 2010. All analyses were weighted using RDS II methods. Prevalence ratios were estimated using average marginal predictions from logistic regression models.

Results: An estimated 17.2% (95% CI, 11.0 to 22.9) of trans Ontarians (median age = 28.7, 77.3% White) did not have a regular family physician. In multivariable analyses accounting for other predisposing and need-related factors, transfeminine persons (trans women and non-binary persons assigned a male sex at birth) who were Indigenous and/or persons of color were less likely than other transfeminine persons to have a family doctor. In addition, trans persons who were homeless or had unstable housing were less likely to have a family doctor than those who were adequately housed.

Conclusions: These results provide the first quantitative evidence of health disparities by race and gender within a Canadian transgender population and suggest a social gradient in access to care within Ontario's “universal health insurance” system.     

Testing Theoretical Explanations of Intention to Seek Care for a Breast Cancer Symptom1

The purpose of this research was to test theoretical explanations of intention to seek care promptly for a breast cancer symptom. Psychosocial variables (affect, expectations, values, and norms), habit, and facilitating conditions (e.g., insurance) regarding care seeking were proposed to influence intention to seek care promptly. Whether psychosocial variables and habit influenced intention directly or in interaction with facilitating conditions remained unclear. Other variables (i.e., clinical and demographic) were proposed to influence intention by mediation through the theoretical variables. Community-dwelling women without history of breast cancer (N= 99) responded to a questionnaire to assess study variables. In a hierarchical set regression, intention was first regressed on psychosocial variables, habit, and full insurance coverage for care, then on terms representing interactions of insurance coverage with psychosocial variables and habit, and lastly on clinical and demographic variables. Findings revealed that (a) anxiety (measure of affect), utility, (the product of expectations and values), and habit were related to intention, (b) having full insurance coverage did not moderate these relationships, and (c) after controlling for theoretical variables, family history of breast cancer was related inversely to intention. Implications for theory, research, and practice are delineated.