Saint-Denis : INPES : 2011 : 258 p.
Ce Baromètre santé décrit les perceptions et les comportements des généralistes en matière de vaccination, de dépistage des hépatites virales et du VIH, de prise en charge des problèmes d'addiction. Pour la première fois, il aborde la prise en charge des patients souffrant de la maladie d'Alzheimer, ou encore la formation en éducation pour la santé ou en éducation thérapeutique du patient. Il permet ainsi de mieux connaître les attentes des médecins, mais aussi les freins à certaines pratiques. Outre une analyse des données chiffrées et de leur évolution dans le temps, l'ouvrage fournit des clés pour comprendre l'implication des médecins généralistes dans le domaine de la prévention.
Wallach D., Kouchner G.
Paris : Springer : 2011 : 289 p.
A partir d'une source bibliographique unique, les articles du "Quotidien du Médecin" parus entre 30 janvier 1971 et le 18 décembre 2009, l'auteur retrace l'histoire du Numerus clausus instauré en France en 1971 à l'entrée en deuxième année des études de médecine. Il détaille les arguments présentés par les partisans et les opposants du Numerus clausus, les motivations universitaires, hospitalières, politiques, économiques, syndicales. Puis, il s'intéresse à la limitation de l'accès au troisième cycle des études médicales mise en place au début des années 1980, sorte de second Numerus clausus. Enfin, dans un dernier point, il relate l'histoire des tentatives qui ont été menées, des années post-68 à la loi HPST (Hôpital, patients, santé et territoires) de 2009, pour modifier les structures de pouvoir dans les hôpitaux.
Brignais : Editions Le Coudrier : 2011 : 191 p.
AFSSAPS, ANSES, CNS, EFS, EPRUS, HAS, INCA, INPES, INVS, ... De nombreux organismes, aux sigles un peu barbares, contribuent à la politique de santé. Comment s'y retrouver ? Quelles sont les missions exactes des uns et des autres ? Que font-ils concrètement ? Comment est piloté le système, pourquoi a-t-il été mis en place et quel est son devenir ? Ce livre apporte une réponse à toutes ces questions. Après un rappel des éléments de contexte (histoire récente, dernières lois), il décrit le dispositif institutionnel concourant à l'élaboration, à la mise en œuvre et au contrôle des politiques sanitaires. Services de l'administration centrale, instances dédiées à la santé publique, agences et établissements publics intervenant en santé, chaque structure est présentée de façon détaillée et illustrée et fait l'objet d'une fiche signalétique rassemblant les informations essentielles. L'auteur propose ensuite une analyse du système d'agences agrémentée d'un tableau d'ensemble. Enfin, à l'heure de la mise en œuvre de la loi Hôpital, patients, santé et territoires, il précise le lien entre l'administration centrale et les nouvelles agences régionales de santé (4e de couverture).
Paris : Le Temps des Cerises : 2010 : 395 p.
Les 1400 à 1500 centres de santé présents en France en 2010 regroupent des structures aux concepts extrêmement différents mais qui restent liés par des statuts communs fixés par la loi et par des valeurs partagées : non lucrativité de la structure, accessibilité sociale à la santé, salariat des professionnels de santé… Ce livre collectif rédigé par une trentaine de professionnels retrace l'histoire, le fonctionnement et la philosophie de ces centres de santé. Face à la crise et à la réforme des collectivités territoriales qui menacent le financement et le développement des centres de santé, cet ouvrage veut témoigner pour l'avenir de ces centres en montrant leur utilité et leur efficience.
Le président de la République a décidé de faire de la dépendance une priorité. On ne pourrait que s'en féliciter, si, derrière des propos qui se veulent humanistes et généreux sur la nécessaire dignité des personnes âgées, ne se profilaient des projets inquiétants. Ils visent tous à remettre en cause les principes fondateurs de la Sécurité sociale basés sur la solidarité nationale. Il s'agit de privatiser la prise en charge des personnes en perte d'autonomie en faisant appel aux assurances privées. Cette expérimentation pourrait servir d'exemple pour être ensuite étendue à d'autres risques couverts aujourd'hui par la Sécurité sociale. Pourtant, d'autres solutions existent : étendre le champ d'intervention de la Sécurité sociale, financer les besoins par une meilleure répartition des richesses produites. Enjeu de société essentiel, la gestion de la perte d'autonomie soulève à la fois la question des solidarités et celle de l'égalité entre les femmes et les hommes (4ème de couv.)
Oxford : Oxford University Press : 2011 : 10p.+381 p.
Epidemiology is often referred to as the science of public health. However, unlike other major sciences, its theoretical foundations are rarely articulated. While the idea of epidemiologic theory may seem dry and arcane, it is at its core about explaining the people's health. It is about life and death. It is about biology and society. It is about ecology and the economy. It is about how myriad aspects of people's lives - involving work, dignity, desire, love, play, conflict, discrimination, and injustice - become literally incorporated into our bodies and manifest in our health status, individually and collectively. And it is about essential knowledge critical for improving the people's health and minimizing inequitable burdens of disease, disability, and death. Woven from a vast array of schools of thought, including those in the natural, social, and biomedical sciences, epidemiologic theory is a rich tapestry whose time for analysis is long overdue. By tracing its history and contours from ancient societies on through the development of - and debates within - contemporary epidemiology worldwide, Dr. Krieger shows how epidemiologic theory has long shaped epidemiologic practice, knowledge, and the politics of public health. Outlining an ecosocial theory of disease distribution that situates both population health and epidemiologic theory in societal and ecologic context, she offers a more holistic picture of how we embody the human experience. This concise, conceptually rich, and accessible book is a rallying cry for a return to the study and discussion of epidemiologic theory: what it is, why it matters, how it has changed over time, and its implications for improving population health and promoting health equity. It should be required (4e de couverture).
Newman J., Tonkens E.
Amsterdam : Amsterdam University Press : 2011 : 241 p.
Faced with budget problems and an aging population, European governments in recent years have begun reconsidering the structure and extent of the welfare state. Guarantees and directives have given way to responsibilities and choice. This volume analyzes the effect of this change on the citizens of Germany, Finland, Norway, the Netherlands, France, Italy and the United Kingdom. It traces the emergence of new discourses around social movements for greater independence, power, and control, and the way these discourses serve to reframe the struggle at hand. Making use of ethnographic research and policy analysis, the authors analyze the cultural transition, tensions, and trajectory of this call toward active citizenship (4e de couverture).
Chichester : Wiley-Blackwell : 2011 : 176 p.
This book offers the most up-to-date analysis of the features and developments of long-term care in Europe. Each chapter focuses on a key question in the policy debate in each country and offers a description and analysis of each system. It also offers the very latest analysis of long-term care reform agendas in Europe .and compares countries comparatively less studied with the experiences of reform in Germany, the United Kingdom, the Netherlands and Sweden.
Rotterdam : Erasmus University : 2009 : 210 p.
It has been known for long that disease and death are unequally distributes over the population. People of lower socioeconomic positions tend to carrya disproportionate amount of the burden of mortality and morbidity. Overweight and obesity are no exception to this. This book starts by describing how large the socioeconomic differences in overweight and obesity currently are in Europe. Related to this, it investigates to what extent these inequalities vary from country to country. It tries to explain the international patterns by looking at country and individual-level factors. It also evaluate to what extent the socioeconomic differences in the prevalence of immediate risk factors mirror the inequality patterns of overweight and obesity. In addition, it investigates the possible role of inequalities in the prevalence of overweight and obesity in socioeconomic difference in the prevalence of diabetes, hypertension and subjectively experienced ill health (4e de couverture).
Intégrée à la plate-forme des bases de données de l'Ocde, elle permet d'accéder aux données statistiques concernant le champ de la santé au niveau international. Les principaux indicateurs disponibles en plusieurs langues sont les suivants :
Etat de santé
Ressources en santé
Utilisation des ressources en santé
Ressources et utilisation des soins de longue durée
Dépenses de santé et financement
Protection sociale Marché pharmaceutique
Déterminants non médicaux de la santé (comportements de santé)
Références démographiques et économiques
Une sélection des tableaux les plus demandés sont disponibles .Il est également possible de sauvegarder et fusionner ses requêtes.
Lancée par le Bureau régional de l'OMS pour l'Europe, au milieu des années 80,la base de données de la Santé pour tous est une source d'information de statistiques sanitaires essentielles. Elle contient des séries chronologiques dont les plus anciennes datent de 1970. La base de données de la Santé pour tous permet de représenter les analyses nationales et internationales sous forme de diagrammes, de courbes ou de cartes, qui peuvent être exportés gratuitement vers d'autres logiciels. La base de données de la Santé pour tous peut être utilisée rapidement en ligne ou téléchargée pour être installée sur un ordinateur dans sa totalité.
Cette base de données est actualisée deux fois par an et reprend quelque 600 indicateurs des 53 États membres européens de l'OMS. Les thématiques couvertes par les indicateurs sont les suivantes : statistiques démographiques et socio-économiques ; la mortalité ; la morbidité, le handicap et les sorties de l'hôpital, les conditions de vie ; santé environnementale, les ressources en santé ; l'utilisation et le coût des ressources en santé, la santé maternelle et infantile.
Cette base de données est développée par l'Agence des Etats-Unis pour le développement international. Elle a pour objectif de pouvoir faciliter la comparaison internationale de la performance des systèmes de santé.
Elle compile des données provenant de sources multiples (OMS, Banque Mondiale, UNICEF, enquêtes démographiques et/ou de santé). L'outil offre une interface interactive avec la possibilité de créer plusieurs types de graphiques et de carte. Le téléchargement des données (données tranversales ou séries chronologiques) est également possible sous différents formats. Des fiches synthétiques par pays peuvent être générées automatiquement.
Les principaux indicateurs des systèmes de santé sont organisés autour de 7 modules principaux : module de base, gouvernance, financement de la santé, la prestation des soins de santé, les ressources humaines, les dépenses pharmaceutique et les systèmes d'information en santé.
Finkelstein A., Taubam S., Wright M.
Cambridge : NBER : 2011/07 : 55 p.
In 2008, a group of uninsured low-income adults in Oregon was selected by lottery to be given the chance to apply for Medicaid. This lottery provides a unique opportunity to gauge the effects of expanding access to public health insurance on the health care use, financial strain, and health of low-income adults using a randomized controlled design. In the year after random assignment, the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected. We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group.
Boone J., Schottmuller C.
Centre for Health Policy Research. (C.H.P.R.). London. GBR
Standard insurance models predict that people with high (health) risks have high insurance coverage. It is empirically documented that people with high income have lower health risks and are better insured. We show that income differences between risk types lead to a violation of single crossing in the standard insurance model. If insurers have some market power, this can explain the empirically observed outcome. This observation has also policy implications: While risk adjustment is traditionally viewed as an intervention which increases efficiency and raises the utility of low health agents, we show that with a violation of single crossing a trade off between efficiency and solidarity emerges.
Castelli A., Nizalova O.
York : University of York : 2011/06 : 30 p.
This paper reports work undertaken for the Department of Health's Payment by Results (PbR) team to investigate whether: the costs associated with specialised activity are significantly different from non-specialised activity within the same Healthcare Resource Group (HRG) ; any differences in costs between specialised and non-specialised activity are due to differences in cost efficiency. This helps address the following PbR objectives: PbR gets the price ‘right' for services, by paying a price that ensures efficiency and value for money for the taxpayer, and incentivises the provision of care that is responsive to individual needs; The system is fair and transparent, through consistent fixed price payments to providers based on volume and complexity of activity. In broad terms, our analysis of data from 2008/9 explores whether patients who receive specialized services as part of their care package have higher costs than those who do not. If so, hospitals that treat more patients who receive specialised care might require top-up payments over and above their PbR tariff income. In our assessment we also take account of other factors that might explain costs. These factors include the Healthcare Resource Group (HRG) to which the patient is assigned, various sociodemographic, diagnostic and treatment-related characteristics of the patient, and the hospital in which the patient is treated. In what follows we first briefly set out the reasons why differential payments might be required for specialised services. We then describe how we identify patients as having received specialised care, assign costs to each patient record in HES, assess the costs of provider spells and decide upon an analytical sample. We specify our multiple regression models before providing some descriptive statistics comparing specialised to non-specialised activity. We then estimate models that investigate the extent to which variations in cost are explained by whether or not a patient received a specialized service.
Stowasser T., Heiss F., McFadden D., Winter J.
Cambridge : NBER : 2011/08 : 36 p.
Much has been said about the stylized fact that the economically successful are not only wealthier but also healthier than the less affluent. There is little doubt about the existence of this socio-economic gradient in health, but there remains a vivid debate about its source. In this paper, we review the methodological challenges involved in testing the causal relationships between socio-economic status and health. We describe the approach of testing for the absence of causal channels developed by Adams et al. (2003) that seeks identification without the need to isolate exogenous variation in economic variables, and we repeat their analysis using the full range of data that have become available in the Health and Retirement Study since, both in terms of observations years and age ranges covered. This analysis shows that causal inference critically depends on which time periods are used for estimation. Using the information of longer panels has the greatest effect on results. We find that SES causality cannot be ruled out for a larger number of health conditions than in the original study. An approach based on a reduced-form interpretation of causality thus is not very informative, at least as long as the confounding influence of hidden common factors is not fully controlled.
Verzulli R., Jacobs R., Goddard M.
York : University of York : 2011/07 : 26 p.
Foundation Trusts (FTs) were introduced in the English NHS in 2004/5 and gave NHS Trusts the opportunity to become independent not-for-profit public benefit corporations. Whilst remaining in the public sector, FTs were granted greater autonomy than non-FTs. The reform was intended to create incentives for providers to deliver higher quality services in the most efficient way. This paper examines the impact of the FT policy on hospital performance, as proxied by measures of financial management, quality of care and staff satisfaction. Results suggest that generally FTs perform better than non-FTs. However, these differences appear to be long-standing rather than the effect of the FT policy per se and we find some evidence of a convergence in hospital performance between FTs and non-FTs.
Bojke C., Goddard M.
York : University of York : 2011/06 : 15 p.
The aim of this review is to provide to the Department of Health an overview of the evidence related to foundation trusts (FTs). It draws on the available research evidence and also on commentary from organisations and individuals. In addition, it provides a brief analysis of FT performance as a means of supplementing the sparse research literature. Four areas are considered below – corporate governance and accountability; finance; quality; and regulation. We conclude with some observations on future policy and research issues.
Lorenzoni L., Pearson M.
Paris : OCDE : 2011/04 : 114 p.
Most OECD countries use a mix of payment arrangements to finance hospital acute care. These lead to various different incentives for the quantity, quality and productive efficiency of hospital services. Of particular interest are per case/diagnosis related group (DRG) payments, which directly relate to actual levels of activity. They are fees established prospectively for a single ?product? delivered by the hospital. In a survey of health systems characteristics carried out in 2009, 17 (out of 29 respondents) OECD countries reported the use of a payment per case/DRG1. But are these DRG-based prices a reliable way of comparing costs across countries? The answer depends crucially on whether the same definitions are used to generate DRG payments across countries. 4. This paper provides a description of the classification systems used to measure hospital services in selected OECD countries: Australia, Canada, England, France, Germany, Norway, and the United States. Three classifications are relevant: those on diagnoses; on procedures ; and on products. In addition, methods used to measure the cost of hospital services are reviewed.
Danzon P.M., Furukawa M.F.
Cambridge : NBER : 2011/07 : 44 p.
This paper examines the role of regulation and competition in generic markets. Generics offer large potential savings to payers and consumers of pharmaceuticals. Whether the potential savings are realized depends on the extent of generic entry and uptake and the level of generic prices. In the U.S., the regulatory, legal and incentive structures encourage prompt entry, aggressive price competition and patient switching to generics. Key features are that pharmacists are authorized and incentivized to switch patients to cheap generics. By contrast, in many other high and middle income countries, generics traditionally competed on brand rather than price because physicians rather than pharmacies are the decision-makers. Physician-driven generic markets tend to have higher generic prices and may have lower generic uptake, depending on regulations and incentives. Using IMS data to analyze generic markets in the U.S., Canada, France, Germany, U.K., Italy, Spain, Japan, Australia, Mexico, Chile, Brazil over the period 1998-2009, we estimate a three-equation model for number of generic entrants, generic prices and generic volume shares. We find little effect of originator defense strategies, significant differences between unbranded and unbranded generics, variation across countries in volume response to prices. Policy changes adopted to stimulate generic uptake and reduce generic prices have been successful in some E.U. countries.
Iezzi F., Lippi-Bruni M., Ugolini C.
Rochester : Social Science Reseach Network : 2011/06 : 34 p.
The design of incentive schemes that improve quality of care is a central issue for the healthcare sector. Nowadays we observe many pay-for-performance programs, where payment is contingent on meeting indicators of provider effort, but also other alternative strategies have been introduced, for example programs rewarding physicians for participation in diseases management plans. Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence health outcomes. We investigate the impact of financial incentives in Regional and Local Health Authority contracts for primary care in the Italian Region Emilia Romagna for the years 2003-05. We focus on avoidable hospitalisations (Ambulatory Care Sensitive Conditions) for patients affected by type 2 diabetes mellitus, for which the assumption of respons ibility and the adoption of clinical guidelines are specifically rewarded. We estimate a panel count data model using a Negative Binomial distribution to test the hypothesis that, other things equal, patients under the responsibility of GPs receiving a higher share of their income through these programs are less likely to experience avoidable hospitalisations. Our findings support the hypothesis that financial transfers may contribute to improve quality of care, even when they are not based on the ex-post verification of performances.
Bonn : IZA : 2011/06 : 23 p.
Although it has long been conjectured that having physicians in leadership positions is valuable for hospital performance, there is no published empirical work on the hypothesis. This cross-sectional study reports the first evidence. Data are collected on the top-100 U.S. hospitals in 2009, as identified by a widely-used media-generated ranking of quality, in three specialties: Cancer, Digestive Disorders, and Heart and Heart Surgery. The personal histories of the 300 chief executive officers of these hospitals are then traced by hand. The CEOs are classified into physicians and non-physician managers. The paper finds a strong positive association between the ranked quality of a hospital and whether the CEO is a physician (p<0.001). This kind of cross-sectional evidence does not establish that physician leaders outperform professional managers, but it is consistent with such claims and suggests that this area is now an important one for systematic future research.
Cambridge : NBER : 2011/06 : 26 p.
The Patient Protection and Affordable Care Act (ACA) is the most comprehensive reform of the U.S. medical system in at least 45 years. The ACA transforms the non-group insurance market in the United States, mandates that most residents have health insurance, significantly expands public insurance and subsidizes private insurance coverage, raises revenues from a variety of new taxes, and reduces and reorganizes spending under the nation's largest health insurance plan, Medicare. Projecting the impacts of such fundamental reform to the health care system is fraught with difficulty. But such projections were required for the legislative process, and were delivered by the Congressional Budget Office (CBO).This paper discusses the projected impact of the ACA in more detail, and describes the evidence that sheds light upon the accuracy of the projections. It begins by reviewing in broad details the structure of the ACA and then reviews evidence from a key case study that informs our understanding of the ACA's impacts: a comparable health reform that was carried out in Massachusetts four years earlier. The paper discusses the key results from that earlier reform and what they might imply for the impacts of the ACA. The paper ends with a discussion of the projected impact of the ACA and offers some observations on those estimates.
Maestas N., Mullen K.J., Strand A.
Santa Monica. The Rand : 2011/03 : 44 p.
The authors present the first estimates of the causal effects of Social Security Disability Insurance receipt on labor supply estimated using the entire population of program applicants. They exploit administrative data to match applications to disability examiners, and use natural variation in examiners' allowance rates as an instrument for the allowance decision in a labor supply equation contrasting denied vs. allowed applicants. Importantly, they find that the disincentive effect is heterogeneous, ranging from a 10 percentage point reduction in labor force participation for those with more severe impairments to a 60 percentage point reduction for entrants with relatively less severe impairments.
Frederiksen A., Kato T.
Bonn : IZA : 2011 : 38 p.
Denmark's registry data provide accurate and complete career history data along with detailed personal characteristics (e.g., education, gender, work experience, tenure and others) for the population of Danish workers longitudinally. By using such data from 1992 to 2002, we provide rigorous evidence for the first time for the population of workers in an entire economy (as opposed to case study evidence) on the effects of the nature and scope of human capital on career success (measured by appointments to top management). First, we confirm the beneficial effect of acquiring general human capital formally through schooling for career success, as well as the gender gap in career success rates. Second, broadening the scope of human capital by experiencing various occupations (becoming a generalist) is found to be advantageous for career success. Third, initial human capital earned through formal schooling and subsequent human capital obtained informally on the job are found to be complements in the production of career success. Fourth, though there is a large body of the literature on the relationship between firm-specific human capital and wages, the relative value of firm-specific human capital has been rarely studied in the context of career success. We find that it is more beneficial to broaden the breadth of human capital within the firm than without, pointing to the significance of firm-specific human capital for career succes.
Cioni M., Siavoli M.
Sienne : Université de Sienne : 2011/02 : 20 p.
The 2007 Italian Labour Force Survey contains employee-level data that allow us to analyse the determinants of work safety. Among the most significant determinants of accidents and illnesses occurring at work we find bad working conditions, not being in the first job, dissatisfaction with the current job, gender, and a latent proneness observed with occurrence of accident on the way to work. In line with the majority of economic literature, we do not find having a fixed-term contract significant. Other important findings point out that work accidents and work illnesses are two deeply correlated phenomena, and that there is a structural break after three years of tenure to be taken into account.
Jones M.K., Latreille M., Sloane P.L.
Bonn : IZA : 2011/06 : 40 p.
This paper uses matched employee-employer data from the British Workplace Employment Relations Survey (WERS) 2004 to examine the determinants of employee job anxiety and work-related psychological illness. Job anxiety is found to be strongly related to the demands of the job as measured by factors such as occupation, education and hours of work. Average levels of employee job anxiety, in turn, are positively associated with work-related psychological illness among the workforce as reported by managers. The paper goes on to consider the relationship between psychological illness and workplace performance as measured by absence, turnover and labour productivity. Work-related psychological illness is found to be negatively associated with several measures of workplace performance.
Abraham J.M., Beeson Royalty A., Deleire T.
Cambridge : NBER : 2011/07 : 33 p.
This study develops an empirical method to assess the generosity of employer-sponsored insurance across groups within the U.S. population. A key feature of this method is its simplicity – it only requires data on out-of-pocket (OOP) health care spending and total health care spending and does not require detailed knowledge of health insurance benefit design. It applies this method to assess whether households with a chronically ill member have more or less generous insurance relative to households with no chronically ill members. We find that the chronically ill have less generous insurance coverage than the non-chronically ill. Additional analyses suggest that the reason for this less generous coverage is not that households with a chronically ill member are in different, less generous plans, on average. Rather, households with a chronically ill member have higher spending on certain types of medical services (e.g., pharmaceutical drugs) that are covered less generously by insurance. Given recent work on value-based insurance design and coinsurance as an obstacle to medication adherence, our findings suggest that the current design of health plans may put the health and financial well-being of the chronically ill at risk.
Jimenez Martin S., Labeaga J.M., Martinez-Granado M.
Madrid : University Carlos III : 1999 : 41 p.
In this paper we use data the European Community Household Panel (ECHP) to describe and analyse the dynamics of joint labour force behaviour of older couples for the EUI2 countries. We focus on three main issues: the relanvance of joint retirement across EUI2 countries, the existence of complementarities in leisure and/or assortative matting and the effects of health variables. Concerning the evidence, we first find that a working spouse is more likely to retire the more recently the other spouse has retired; this effect is stronger if the wife is the working spouse. Second, there is evidence of assortative mating and/or complementarities in leisure; the effects of all relevant factors on the retirement decision of one spouse depend strongly on whether the other one is working, unemployed, or retired. Third, besides the standard evidence that poor health increases the retirement probabiliby, we find that the husband's health affects the couple's retirement decisions much more strongly than the wife's health does. Additional asymmetric effects are detected with respect to income related variables.
Bradley C.J., Neumark D., Motika M.I.
Cambridge : NBER : 2011/07 : 15 p.
This paper studies how men's dependence on their own employer for health insurance affects labor supply responses and loss of health insurance coverage when faced with a serious health shock. Men with employment-contingent health insurance (ECHI) are more likely to remain working following some kinds of adverse health shocks, and are more likely to lose insurance. With the passage of health care reform, the tendency of men with ECHI as opposed to other sources of insurance to remain employed following a health shock may be diminished, along with the likelihood of losing health insurance.