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PubMed1992

The fate of mental health services in health care reform: II. Realistic solutions.

In the second part of a two-part paper, the three major proposals for U.S. health care reform--the government-sponsored model, the employment-based model, and the market reform model--are reviewed. Barriers to their success include the current economic crisis, the lack of a clear consensus, and the high costs of the proposals. Most proposals limit the extent of psychiatric coverage; some exclude such coverage from minimum benefit packages, an area of concern for clinicians. The author concludes that any substantial health care reform is unlikely in the near future. A thoughtful, realistic, and yet vigorous strategic plan is needed now to forestall the possible exclusion of significant mental health coverage. The basic elements of such a plan are reviewed.

Cost Control↗
PubMedDate not supplied

The decline in health insurance and labor market trends.

Since the mid-1980s, there has been a reduction in the percentage of workers with employment-based health insurance. In 1993, 68.6 percent of workers had this insurance, compared with 72.9 percent in 1988. The decline was slightly more pronounced among workers obtaining their insurance indirectly, i.e., through someone else's employer. There was a decline in direct employment-based health insurance (coverage through one's own employer) with proportions dropping from 56.1 percent in 1988 to 54.1 percent in 1993. The model used in this analysis identified the factors associated with the decline in employment-based health insurance. The data used were those from the 1989 and 1994 supplements to the Current Population Survey (CPS) conducted by the U.S. Bureau of the Census. The data analyses identified about 55 percent of the factors influencing decreases in employment-based coverage between 1988 and 1993. These factors include decreases in real wages, a small movement toward the use of part-time workers, movements from the goods-producing sector to the service-producing sector, changes in unemployment rates, rising health care costs and the changing racial composition of the work force. The relative proportion each of the factors contributed to the decline, as well as the counterbalancing influence of age, education, firm size, occupation and marital status is discussed.

Adolescent↗
PubMed1988

Financing long-term care. Health and Public Policy Committee. American College of Physicians.

The availability and delivery of long-term care services in the United States have been hindered by major organizational and financial problems. The American College of Physicians has previously identified and addressed some of the organizational problems that impede access to long-term care. In this issues paper, we provide background information on and analysis of the costs and the methods currently used to finance such care in the United States. The Canadian National Health Care System is also described for comparison. We then analyze such alternative financing mechanisms as private individual insurance (beyond Medigap), employment-based long-term care insurance, self-insurance, vouchers, financing through Medicare, home equity conversions, and prepaid capitated case management plans. The advantages and disadvantages of each of these methods are presented.

Aged↗
PubMed1990

The 'Medicaidization' of AIDS. Trends in the financing of HIV-related medical care.

Among patients with the acquired immunodeficiency syndrome (AIDS) who were hospitalized in New York City, San Francisco, Calif, and Los Angeles, Calif, from 1983 through 1988, we observed a marked shift in the payer distribution toward Medicaid and away from private insurance. This trend, which we refer to as the "Medicaidization" of AIDS, occurred among whites as well as blacks and Hispanics and increased the burden on public hospitals and emergency rooms. "Medicaidization" jeopardizes access to office-based primary care because of very low reimbursement rates that are paid to physicians by Medicaid relative to private insurance. Policies designed to prevent the loss of employment-based private insurance would slow or reverse the trend to public financing. Increasing Medicaid reimbursement will improve access to care.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Urban and rural differences in health insurance and access to care.

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies. Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P < 0.01). These differences were confirmed by multivariate analysis. Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.

Adult↗
PubMed1983

"Procompetition" and the continuing struggle to contain health-care costs.

Various proposals designed to increase competitive forces in the health-care services economy are discussed. Two concepts inherent in market-oriented strategies for containing health-care costs--cost sharing and fixed-dollar subsidies--are defined. Among the strategies for increasing market forces in health care are (1) increasing consumer choice, (2) increasing consumer cost sharing, (3) modifying tax treatment of insurance and medical care, (4) controlling the terms of employment-based insurance, and (5) application of antitrust law. Specific conceptual and legislative "procompetition" proposals are summarized. All of the "procompetition" proposals offer economic incentives for good management of hospitals as a whole as well as for individual departments such as the pharmacy.

Cost Control↗
PubMed1996

Trends in health insurance coverage in California, 1989-1993.

California's uninsurance rate of 22.7 percent is higher than the national average. The state's rate of employment-based insurance coverage--below the national average--is declining because of rising health insurance premiums, falling family incomes, and the changing structure of the economy and the labor market. Growing Medicaid coverage, fostered by expanded eligibility and falling incomes, has prevented rapid growth in the state's uninsured population. Anticipated cutbacks in federal Medicaid funding, however, would increase California's uninsurance rate. Continuing cutbacks in health services for the uninsured would reduce their access to health care and increase stress on many private health services.

Adolescent↗
PubMed1995

Medicare coverage, supplemental insurance, and the use of mammography by older women.

BACKGROUND: On January 1, 1991, the Medicare program began offering reimbursement for screening mammography every two years. This study examined the use of mammography in women covered by Medicare during the first two years that the screening benefit was offered. METHODS: Medicare bills for 1991 and 1992 from a nationally representative sample of 4110 women 65 years of age or older were examined to determine the degree of compliance with recognized guidelines for screening mammography and the extent to which the use of mammography was associated with having supplemental insurance, which shields patients from the out-of-pocket costs associated with using Medicare benefits. RESULTS: A total of 36.9 percent of older U.S. women had mammography during the first two years of the Medicare benefit for screening mammography. Only 14.4 percent of the women lacking supplemental insurance had mammography, as compared with 44.7 percent of those with employer-sponsored supplemental insurance, 40.1 percent of those with self-purchased supplemental insurance, and 23.9 percent of those with Medicaid supplemental insurance. These differences persisted in the stratified and multivariate analyses. As compared with women lacking supplemental insurance, women with employment-based supplemental insurance were more likely to undergo mammography (adjusted odds ratio, 3.03; 95 percent confidence interval, 2.17 to 4.23), as were women with self-purchased supplemental insurance (adjusted odds ratio, 2.97; 95 percent confidence interval, 2.13 to 4.15) and women with Medicaid supplemental insurance (adjusted odds ratio, 1.99; 95 percent confidence interval, 1.30 to 3.07). CONCLUSIONS: The use of mammography was substantially below recommended levels during the first two years of Medicare coverage for screening mammography. Women lacking supplemental health insurance were at particularly high risk of failing to undergo mammography. Requiring copayments for preventive services is an obstacle to the effective mass screening of older women for breast cancer.

Aged↗
PubMed1991

Defining geographic areas to adjust payments to physicians, hospitals, and HMOs.

Defining geographic areas for the purpose of paying health care providers has been difficult and is an issue that Congress continues to address. Employment-based insurance programs are starting to face this same issue in paying HMOs. Because input prices are related to population density, payment levels could be related to density. This paper offers a new measure of density that represents the population density for the average person. Using zip-code-level data, this measure calculates density of a county weighted by the population of the zip code. Payment areas can be devised by using the measure to categorize counties. This approach can be applied to paying physicians, hospitals, and HMOs.

Catchment Area, Health↗
PubMedDate not supplied

Japanese hospitals--culture and competition: a study of ten hospitals.

Japanese health care is characterized by a pluralistic system with a high degree of private producers. Central government regulates the prices and the financing system. All citizens are covered by a mandatory employment-based health insurance operating on a non-profit basis. The consumer has a free choice of physician and hospital. A comparison between Japan, Sweden and some other countries shows significant dissimilarities in the length of stay, number of treatments per hospital bed and year and the staffing of hospitals. About 80 per cent of the hospitals and 94 per cent of the clinics are privately owned. The typical private hospital owned by a physician has less than 100 beds. In this paper, data collected (1992/93) in an empirical study of Japanese hospitals and their leadership is presented. Also discussed are the hospitals' style of management, tools and strategies for competition and competences--personal and formal skills required of the leadership in the hospital. There follows a study of ten hospitals, among which hospital directors and chief physicians were interviewed. Interviews are also made with key persons in the Ministry of Health and Welfare and other organizations in the health care field. The result is also analysed from a cultural perspective--'what kind of impact does the Japanese culture have on the health care organization?' and/or 'what kind of sub-culture is developed in the Japanese hospitals'. Some comparisons are made with Sweden, USA, Canada and Germany. The different roles of the professions in the hospital are included in the study as well as the incentives for different kinds of strategies--specialization, growing in size, investments in new equipment, different kind of ownership and hospitals. Another issue discussed is the attempt to uncover whether there is an implicit distribution of specialties--silent agreements between hospitals, etc.

Economic Competition↗
PubMed1997

Long-term determinants of patterns of health insurance coverage in the Medicare population.

Using data from the 1990 Health Supplement to the Panel Study of Income Dynamics, we examine the determinants of patterns of insurance coverage among the elderly. Among those with supplemental insurance through an employment-based source, the primary determinant of having insurance is work history, specifically job tenure and occupation of household heads and their spouses. Among those who do not have employer-provided insurance, wealth is the most important economic factor in the purchase of private insurance. Blacks, persons with less education and women household heads are less likely to purchase supplemental insurance. We find little evidence that persons in prior poor health are more likely to purchase supplemental insurance, and the most important determinant of dental or drug coverage is having employer-based insurance. The current trend toward decreased generosity of post-retirement benefits implies that fewer older Americans will have insurance for these services.

Black or African American↗
PubMed1992

Universal health care coverage--pitfalls and promise of an employment-based approach.

America's patchwork quilt of health care coverage is coming apart at the seams. The system, such as it is, is built upon an inherently problematic base: employment. By definition, an employment-based approach, by itself, will not assure universal coverage of the entire population. If an employment-based approach is to be the centerpiece of a system that provides universal coverage, special attention must be paid to all the categories of individuals who are not employees--children, unemployed spouses or singles, the unemployable ill and disabled, persons between jobs, students, retirees, the elderly. Moreover, in a purely voluntary employment-based arrangement, some employers will not provide insurance at all, and others will provide inadequate coverage, necessitating other special provisions for coverage. As a consequence, about one out of six people now has no health coverage whatsoever, and even more have inadequate coverage. All the while, the rapidly-increasing transaction costs of sustaining this grossly inadequate pluralistic system eat up sufficient funds to provide basic benefits to the entire population. The time for systematic reforms has come and gone; what is now needed is action to prevent disaster, followed by a complete rebuilding of this country's health coverage system. Although perhaps more likely to be tried than more radical, completely nationalized, ones, stepwise reforms may not go far enough to cure the significant ills of the current employment-based system. Passage of inadequate reforms, then, could well set the stage for nationalized health care in the not too distant future.

Employer Health Costs↗
PubMed1995

Employment-based health insurance: implications of the sampling unit for policy analysis.

One of the least understood aspects of using employer data for the health reform debate concerns important differences between enterprise- and establishment-level surveys of employers. We demonstrate that the choice of sampling unit affects the size distribution of employees between large and small firms, as well as the estimated proportion of firms offering health insurance. Because health insurance decisions in multi-establishment enterprises generally are made for the entire enterprise rather than individual establishments, we conclude that enterprise surveys are most appropriate for collecting information on the factors affecting the decision to provide health insurance coverage. Nevertheless, an establishment-level survey may be preferred for evaluating decisions made at the state, regional, or industry level. But establishment-level surveys will underestimate the impact of an employer mandate on the unit that ultimately makes the decision to offer health insurance--the enterprise. Given the enormous human and financial stakes involved in health care reform, we urge policymakers and analysts to reflect on the strengths and limitations of alternative sampling units, and to consider the implications for interpreting survey data and formulating policy decisions.

Fee-for-Service Plans↗
PubMedDate not supplied

How will changes in health insurance tax policy and employer health plan contributions affect access to health care and health care costs?

OBJECTIVE: To understand how changes in federal taxation of and employer contributions to health insurance benefits affect the decisions of firms to offer insurance, the willingness of households to purchase different health plans, and the resultant health expenditures. DESIGN: Economic policy simulation. SETTING: Secondary data analysis. PARTICIPANTS: A total of 18,343 sampled families (representing 77 million total families throughout the United States) with a working household head from the 1988 Current Population Survey who were not covered by either Medicare, Medicaid, or CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) insurance. INTERVENTIONS: One intervention limits the amounts of tax-free employer contributions to health insurance premiums to 80% of our estimate of the base plan in the market and assumes that employer contributions will also be limited to this maximum. A second intervention eliminates the favorable tax treatment of employer-paid premiums altogether and assumes that employees will pay the full price of insurance. MAIN OUTCOME MEASURES: Change in the number of working families offered employment-based insurance, change in insurance plan choice, and change in medical spending. RESULTS: Capping the favorable tax treatment and employer contributions decreases the number of families offered employment-based insurance by approximately 91,000, increases the number of families selecting the least generous insurance plan from 20% under the current situation to 33%, and reduces overall health spending by less than 2%. By eliminating the tax exemption altogether, the number of families offered employment-based insurance decreases by approximately half a million families, the number of families selecting the least generous plan goes from 20% to 40%, and overall spending falls by about $16 billion. CONCLUSIONS: Eliminating the tax subsidy and limiting employer-paid contributions to the low-cost plan substantially increases the number of low-income uninsured under a voluntary insurance system, decreases overall spending only modestly, but would raise tax revenues by $36 billion. These tax revenues could be used to assist low-income families to obtain insurance coverage.

Competitive Medical Plans↗
PubMed1994

Health system reform in the Czech Republic. Policy lessons from the initial experience of the general health insurance company.

The Czech Republic is among the most aggressive of the former Warsaw Pact countries in encouraging competition and free-market reform. This aggressiveness was extended into the health care sector when, in 1992, a mandatory employment-based health insurance system was introduced. The move from a controlled socialist structure to an insurance-based, fee-for-service model occurred in a short time. Health care spending increased 50% in 2 years and now approaches that of many industrialized nations. Claims for reimbursements are increasing at a rate of 5% to 7% per quarter. Market incentives have changed behaviors within the medical community. Newly privatized physicians generate greater volume and consume more resources than those continuing as state employees. Policy issues requiring further evaluation include supply, distribution, and relative valuation of physician services; clinical resource allocation; and cost containment.

Czech Republic↗
PubMed1993

The effect of HMOs on premiums in employment-based health plans.

This study documents the effect of HMOs on premiums in employment-based health plans. We analyzed a survey of Minnesota employers conducted in 1986. Among 922 usable observations, 239 firms offered HMOs in addition to fee-for-service (FFS) health plans. We estimated an equation for the probability of offering an HMO, followed by equations for HMO enrollment share, and HMO and FFS premiums. The weighted average HMO and FFS premium in firms that offer HMOs was compared to the premium of FFS-only firms. We found that offering an HMO raises the average premium for family coverage health insurance by $25.14 per month and for single coverage by $3.68 per month. This effect was smaller for firms in the Twin Cities metropolitan area. HMOs may be viewed as a progressive and innovative health care benefit, but they are likely to increase firms' health insurance premiums.

Cost Sharing↗
PubMed1996

Family, work, and access to health insurance among mature women.

We use a life course approach to address much ignored variation in access to health insurance. Using data from the National Longitudinal Survey of Mature Women, we reinterpret the role of both family and employment characteristics in shaping coverage. Mature women are more likely to be insured as wives than as workers, but that safety net is only available to married women. As a result, unmarried women are two to three times as likely to be uninsured or to rely on public programs such as Medicaid. And because they are significantly less likely to be married to a covered worker, Black women are two to three times more likely to be uninsured or to rely on public programs. Given rising instability in employment and marital status across the life course, stable health insurance coverage can only be attained by universal rather than employment-based or family-based schemes.

Adult↗