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PubMed2003

Unmanaged care: towards moral fairness in health care coverage.

Health insurers are generally guided by the principle of "actuarial fairness," according to which they distinguish among various risks on the basis of cost-related factors. Thus, insurers often limit or deny coverage for vision care, hearing aids, mental health care, and even AIDS treatment based on actuarial justifications. Furthermore, approximately forty-two million Americans have no health insurance at all, because most of these individuals cannot afford the cost of insurance. This Article argues that Americans have come to demand more than actuarial fairness from health insurers and are increasingly concerned by what I call "moral fairness." This is evidenced by the hundreds of laws that have been passed to constrain insurers' discretion with respect to particular coverage decisions. Legislative mandates are frequent, but seemingly haphazard, following no systematic methodology. This Article suggests an analytical framework that can be utilized to determine which interventions are appropriate and evaluates a variety of means by which moral fairness could be promoted in the arena of health care coverage.

Actuarial Analysis↗
PubMed1992

A universal access plan: a step toward national health insurance?

There is increasing interest by the public and by many providers in the enactment of a universal access plan for the more than 60 million Americans who are now without health insurance benefits at some time during each year. After discussing the heterogeneous characteristics of those such a plan would cover, the reasons that some key players are now supporters of a minimal benefit plan, and the funding options for such a proposal, it is concluded that there is growing support for a universal access plan to be enacted soon. The almost insurmountable issues of such a plan involve the determination of eligibility and the specific benefits to be provided, the cost and administration of the new coverage, and the predictable increase in the nation's expenditure for health care services. This article concludes with the opinion that the passage of a universal access plan is a necessary and incremental step that will provide additional time for the discussion of whether and, if so, when the United States will be prepared to implement the final steps toward a more single-payer, centrally controlled health care delivery system.

American Medical Association↗
PubMed2003

Winners and losers: expansion of insurance coverage in Russia in the 1990s.

OBJECTIVES: This study sought to describe the evolution of the Russian compulsory health insurance system and to identify factors associated with noncoverage. METHODS: Data from successive waves of the Russian Longitudinal Monitoring Survey (1992-2000) were analyzed. RESULTS: Insurance coverage grew rapidly throughout the 1990s, although 11.8% of the country's citizens were still uninsured by 2000. Coverage initiation rates were greater at first among citizens who were better off, but this gap closed over the study period. Among individuals of working age, coverage rates diminished with age and were lower for the unemployed, for the self-employed, and for those residing outside Moscow or St. Petersburg. CONCLUSIONS: The growth of insurance coverage in Russia slowed toward the end of the 1990s, and gaps remain. Achievement of universal coverage will require new, targeted policies.

Adult↗
PubMed2006

Inequity in mental health care under Canadian universal health coverage.

OBJECTIVE: Previous research has produced conflicting evidence about socioeconomic disparities in mental health care under universal health coverage in Canada. This study sought to determine equity in the delivery of ambulatory services from psychiatrists and family physicians for mental health problems in this setting. METHODS: Outpatient billing claims and neighborhood socioeconomic status were examined with cross-sectional analysis. The study area consisted of the central southern portion of the city of Toronto, Ontario, including the city's downtown core. This urban setting is an economically and culturally diverse area. A total of 1,221 homogeneous enumeration areas (local neighborhoods) were surveyed, and data were examined for the 746,141 residents of these areas who had had a health visit in 2000. Rates of mental health visits to family physicians and psychiatrists were compared across socioeconomic quintiles. Socioeconomic status was determined according to educational attainment in the enumeration area. RESULTS: Claimants from neighborhoods with the highest socioeconomic status were 1.6 times as likely as those from neighborhoods with the lowest socioeconomic status to use psychiatric care. Among persons who received care from a psychiatrist, claimants from neighborhoods with the highest socioeconomic status had significantly more psychiatric claims than those from neighborhoods with the lowest socioeconomic status. No significant gradients were found for either sex for any use of mental health care provided by family physicians. Among females, service users from the highest socioeconomic areas had more mental health visits to family physicians than those from the lowest socioeconomic areas. CONCLUSIONS: Marked socioeconomic disparities were found in the use of care from a psychiatrist. Unlimited coverage of physician-provided mental health care is insufficient to fairly distribute services to those most in need.

Adult↗
PubMed1998

Cream-skimming in deregulated social health insurance: evidence from Switzerland.

Policymakers fear that health insurers when exposed to competition will engage in cream-skimming (i.e. selection of good risks) rather than trying to improve their benefit to premium ratio. This fear surfaced also when Swiss federal government proposed pro-competitive Law on social health insurance, which barely passed a popular referendum in 1994. While a risk equalization mechanism based on age, gender, and place of residence has already been created, there is a considerable interest in improving its formula. This paper shows that a dummy variable indicating an individual's death during the period of observation causes the coefficient of determination to jump from 0.039 to 0.111. More-over, simulations of the risk selection process suggest that risk equalization should be made a permanent institution rather than being limited to a life of 10 years as prescribed by present legislation. In fact, the formula in use, with all its shortcomings, can be shown to neutralize to a great extent insurer interest in cream skimming provided he takes a longer-run view.

Actuarial Analysis↗
PubMed2002

Expanding the scope of health reform: application in the United States.

Since the demise of the Clinton national health plan in the early 1990s, a number of states in the US have continued to pursue health reform. The reforms reflect the on-going debate in the US and throughout the world over market-minimizing versus market-maximizing strategies to improve healthcare systems. This paper describes the limits of this debate and supports a broader view that focuses on how health policy can improve population health. Performance measures and indicators traditionally used to evaluate market minimizing/maximizing strategies for reforming healthcare are redefined for evaluating strategies to improve health. Differences in the two views are illustrated by describing state reforms in the US using the market-minimizing/maximizing framework and evaluating the reforms based on the health-related framework.

Acute Disease↗
PubMed2002

Health insurance and mammography: would a Medicare buy-in take us to universal screening?

OBJECTIVE: To determine whether health insurance expansions via a Medicare buy-in might plausibly increase mammography screening rates among women aged 50-64. DATA SOURCES: Two waves of the Health and Retirement Study (HRS) (1994, 1996). STUDY DESIGN: A longitudinal study with most explanatory variables measured at the second wave of HRS (1994); receipt of mammography, number of physician visits, and breast self exam (BSE) were measured at the third wave (1996). DATA EXTRACTION: Our sample included women aged 50-62 in 1994 who answered the second and third HRS interview (n = 4,583). PRINCIPAL FINDINGS: From 1994 to 1996, 72.7 percent of women received a mammogram. Being insured increased mammography in both unadjusted and adjusted analyses. A simulation of universal insurance coverage in this age group increased mammography rates only to 75-79 percent from the observed 72.7 percent. When we accounted for potential endogeneity of physician visits and BSE to mammography, physician visits remained a strong predictor of mammography but BSE did not. CONCLUSION: Even in the presence of universal coverage and very optimistic scenarios regarding the effect of insurance on mammography for newly insured women, mammography rates would only increase a small amount and gaps in screening would remain. Thus, a Medicare buy-in could be expected to have a small impact on mammography screening rates.

Breast Self-Examination↗
PubMed1997

Managed care: how economic incentive reforms went wrong.

In its response to pressures to rationalize health care resource allocation, the American health care system has embraced managed care without concurrent comprehensive health care reform, either in the form of the centralized tax-based systems found in Europe and Canada or that of the Clinton reform plan. What survives is managed care without managed competition, employer mandates, or universal access. Two problems inherent in the incentive structure of managed care plans developed in the absence of comprehensive health care reform work against the public interest. First, sacrifices in terms of medical innovation and quality of care may not be offset by greater equity in the distribution of health care. Second, such managed care plans fail to address the need for long-term accountability.

Biomedical Technology↗
PubMed1997

Health care reform is dead--long live health care reform.

The 1993 Clinton health care reform effort was not the end of reform but the inauspicious start of a fiercely contested round of reform that may take another decade or two to complete. The 1993 Clinton plan was just the latest stage of a battle for national action on health care than began with Teddy Roosevelt's promise of compulsory health insurance in the 1912 presidential campaign.

Health Care Reform↗
PubMed2002

The Danish health system through an American lens.

The organization and financing of the Danish health care system was evaluated within the framework of a SWOT analysis (analysis of strengths, weaknesses, opportunities and threats) by a panel of five members with a background in health economics. The evaluation was based on reading an extensive amount of selected documents and literature on the Danish health care system and a 1-week visit to health care authorities, providers and key persons. The present paper includes the main findings by one of the panel members. Primary care is much more accessible in Denmark than the USA. A mixed capitation-fee-for-service method of paying generalist physicians in Denmark ensures that everyone has a primary care physician and generalist physicians are responsive to providing services quickly, typically same-day appointments. An organized off-hours service ensures accessible care 24 h a day, 7 days a week. Denmark has the highest public satisfaction with health care, reflecting the value placed on accessibility of primary care. Inpatient hospital care consumes a disproportionate share of Danish health expenditures. Global hospital budgets provide little incentive for hospital or surgical productivity. Long waits for hospitalization, especially surgical procedures and cancellation of scheduled surgery, are a source of patient dissatisfaction. Women's health, patient health risk counseling and coordination of preventive and primary care are major weaknesses of the Danish health system. Patients have a choice of primary care physician within a given geographic area and may go to a hospital of their choice. However, patient surveys and feedback are underdeveloped and very little effort has been made to make services responsive to patients' preferences. While innovations in electronic prescribing are noteworthy, further development of health information technology is needed.

Delivery of Health Care↗
PubMed2006

Basic oral health needs: A professional priority?

The inadequacy of access to oral health care is a complex problem facing society. Many in society who need care are unable to obtain it or do not seek it for a variety of reasons. Most commonly, these are the unfunded, who simply have inadequate resources; the "unaccepted," who may not have dental coverage or have types of coverage that are not accepted by private practitioners; the inaccessible, who may be homebound or live in sparsely populated or low-income geographic areas without dental providers; the unconvinced, who may have resources but do not believe in or recognize the need for treatment; and the unmotivated, who may realize that they need care but for them it is not a priority. While the oral health care professions cannot be expected to shoulder the entire burden to "fix" inadequate access to care, we believe that they have important responsibilities. True professions have a unique relationship with society that places them in positions of trust. With this trust comes the responsibility for public policy advocacy and to actively participate in identifying realistic ways to reduce the access problem. The leadership of organized dentistry, as well as educational institutions, and practitioners themselves must be committed to improving access and thereby the health of those currently underserved.

Attitude of Health Personnel↗
PubMed2003

A policy transformed by politics: the case of the 1973 Australian Community Health Program.

During an era of health policy reform in Australia, community health advocates believed that community health centers (CHCs) could form a solid foundation for a new system of health care delivery. Instead, a proposal for national health insurance (Medibank) emerged as the predominant structural reform. Community health proposals were not abandoned, however, and a policy designed to give federal grant assistance for the establishment of CHCs was implemented in 1973. The historical account of how the 1973 Australian Community Health Program (CHP) was developed in the early 1970s is relevant to dilemmas faced by contemporary policy makers. Specifically, how did the CHP "survive" even though government leaders had moved away from traditional direct service models, choosing to focus more attention on indirect insurance reimbursement?

Australia↗
PubMed2000

Consumer empowerment as a solution to health system financing.

The health system of the welfare state has basic design flaws. First, it treats citizens as recipients of entitlements that are bestowed on them rather than as sovereign customers who otherwise can choose among an array of goods and services; with uniform health plans, there are no incentives to economise. Second, benefits are provided by government through monopoly schemes; their performance has been dismal when compared with other sectors of the economy that, under competition, have yielded continuous efficiency improvements. Ceaselessly rising costs for healthcare are the consequence. Applying the principles of the market economy to healthcare--and to social security in general--would unleash a vast potential of efficiency gains. The issue in such a reform is equity. Healthcare must be affordable for all. In reconciling efficiency and equity, the cornerstones of this proposal are financial empowerment and individual responsibility; to hand the individual the money required to purchase the current level of benefits--nobody loses--and to leave it to the individual, within bounds, whether to do so. While guaranteeing that everybody can buy the current benefits, the savings from restraint will be the individual's to keep. The reform steps would be as follows: (i) empowerment, (ii) fairness and finance, (iii) safeguard and choice, and (iv) savings to keep. This is a 'consumer model' of healthcare. Efficiency is achieved by privatisation, individual responsibility and freedom of choice on the demand side and by competition on the supply side. Equity is guaranteed by financial empowerment of the individual and a no-loss rule; mandatory minimum insurance would preserve the safety net.

Community Participation↗
PubMed2005

Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a canadian setting.

OBJECTIVE: To determine whether rates of physician visits for ambulatory care sensitive (ACS) conditions are lower for people of low-socioeconomic status than of high-socioeconomic status in an urban population with universal health care coverage. DATA SOURCES/STUDY SETTING: Physician claims and hospital discharge abstracts from fiscal years 1998 to 2001 for urban residents of Manitoba, Canada. The 1996 Canadian Census public use database provided neighborhood household income information. The study included all continuously enrolled urban residents in the Manitoba Health Services Insurance Plan. STUDY DESIGN: Twelve ACS conditions definable using 3-digit ICD-9-CM codes permitted cross-sectional and longitudinal comparison of ambulatory visits and hospitalizations. Neighborhood household income data provided a measure of socioeconomic status. DATA COLLECTION/EXTRACTION METHODS: Files were extracted from administrative data housed at the Manitoba Centre for Health Policy. PRINCIPAL FINDINGS: All conditions showed a socioeconomic gradient with residents of the lowest income neighborhoods having both more visits and more hospitalizations than their counterparts in higher income areas. Six of nine conditions with a sufficient N showed individuals living in the lowest income neighborhoods to have significantly more ambulatory visits before hospitalization for an ACS condition than did those in the most affluent neighborhoods. Many conditions showed a gradient in rate of hospitalization even after controlling for the number of ambulatory care visits. CONCLUSIONS: In the Canadian universal health care plan, the poor have reasonable access to ambulatory care for ACS conditions. Ambulatory care may be more effective in preventing hospitalizations among relatively affluent individuals than among the less well off.

Adolescent↗