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Understanding the uninsured dilemma. A necessity for managed care survival.
As we approach 2000, health care cost, quality and access continue to be highly debated issues within managed care and the health care delivery system. Of these, perhaps there is no single issue more contested among consumers than the average cost of health care. Factors affecting the cost of health care are many. However, the uninsured population is one of the most visible and difficult to predict. Leaders in managed care have extensively studied this problem for several years; however, there continues to be no consensus on the best way to capture the nearly 42 million uninsured, reprogram scarce health care resources or provide access into the health care delivery system for everyone while maintaining existing quality, cost containment measures and administration. This paper outlines the scope and impact of the uninsured in managed care and profiles initiatives in controlling the population.
Medipay for medical bills.
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Thoughts on affordable health care.
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Return to Jackson Hole? The push for a standard benefit.
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NAS calls for universal health care. 'Dire situation' underscored by rising costs.
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Models for universal health care: how to fix a broken system.
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[Italy: a national health service with a tumultuous history].
During the 70's, various political forces succeeded to combine their efforts and launched a health reform. The system based on sickness insurance funds each serving a specific social or occupational group was replaced by a universal system covering all the citizens. During the 80's, the reformist context disappeared, the basic units of the new system (U.S.L.) became extremely politicized, resources subsidized by the State became scarce, the people frustrated. At the beginning of the 90's, a new reform was launched, aimed at raising the management level of the USL (ambulatory care) and the large hospitals. At the same time, more financial and managerial responsibilities were transferred to the regions. During these decades, the Italian reform attempted to implement several foreign models. But a long time was wasted in debates and discussions. When the implementation started, these models became outdated and the authors inspiring the reform disappeared themselves from the stage.
Labor rekindles reform.
The health care crisis is back. There is intensifying sentiment across the country that universal coverage is our only way out. The labor movement has used historically such opportunities for change to win health benefits at the bargaining table and strengthen the social safety net. Eighty years of incremental victories and many failed attempts at major health reform have taught labor a crucial lesson: we must build a powerful grassroots movement to drive our effort to achieve universal coverage, or it is doomed to be corrupted by those wedded to the status quo. Now is the right time for reform.
Poor program's progress: the unanticipated politics of Medicaid policy.
Advocates of U.S. national health insurance tend to share an image that highlights universal standards of coverage, social insurance financing, and national administration--in short, the basic features of Medicare. Such an approach is said to be good (equitable and efficient) policy and equally good politics. Medicaid, by contrast, is often taken to exemplify poor policy and poorer politics: means-tested eligibility, general revenue financing, and federal/state administration, which encourage inequities and disparities of care. This stark juxtaposition fails, however, to address important counterintuitive elements in the political evolution of these programs. Medicare's benefits and beneficiaries have stayed disturbingly stable, but Medicaid's relatively broad benefits have held firm, and its categories of beneficiaries have expanded. Repeated alarms about "bankruptcy" have undermined confidence in Medicare's trust funding, while Medicaid's claims on the taxpayer's dollar have worn well. Medicare's national administration has avoided disparities, but at the price of sacrificing state and local flexibility that can ease such "reforms" as the introduction of managed care. That Medicaid has fared better than a "poor people's program" supposedly could has provocative implications for health reform debates.
Health care reform and social movements in the United States.
Because of the importance of grassroots social movements, or "change from below," in the history of US reform, the relationship between social movements and demands for universal health care is a critical one. National health reform campaigns in the 20th century were initiated and run by elites more concerned with defending against attacks from interest groups than with popular mobilization, and grassroots reformers in the labor, civil rights, feminist, and AIDS activist movements have concentrated more on immediate and incremental changes than on transforming the health care system itself. However, grassroots health care demands have also contained the seeds of a wider critique of the American health care system, leading some movements to adopt calls for universal coverage.
The chances for health care reform.
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The new politics of U.S. health policy.
Following the demise of comprehensive health care reform in 1994, some reformers are seeking comfort in the successful "incremental" strategy for enacting Medicare that emerged out of President Harry Truman's failed campaign for national health insurance in 1948-50. But despite similarities between the Truman and Clinton health security efforts, overall contexts of government and politics are much less hospitable to governmentally funded reforms today than they were after Truman's defeat. Back then, market transformations and political dynamics were both pushing toward expanded access to health services and insurance coverage. Today, by contrast, both push in the opposite direction. The private insurance market is fragmenting, federal budgetary constraints stymie new programs, and the deficit dominates debate over existing programs. Equally important, a stable pro-reform coalition like that of Truman's day has yet to emerge, while a new and fiercely conservative corps of Republicans is championing coherent programmatic alternatives based on antigovernment premises. Although passage of the Kassebaum-Kennedy health insurance reform bill in 1996 unleashed a wave of enthusiasm about incremental health care reform, formidable political, fiscal, and technical obstacles continue to stand in the way of even relatively modest incremental solutions.
The politics of health reform: why do bad things happen to good plans?
This paper examines political feasibility and its implications for health reform. I discuss the political obstacles to health reform in the United States, disentangling perennial barriers from contemporary constraints. I then explore major reform options and their political prospects. I argue that while incremental reform now appears to be the most feasible option, the political climate may change in a way that permits a bolder vision. Moreover, incremental reform may not be sustainable in the long run, for the same reason that makes it politically popular now: It does not change the status quo in the health system.