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Physician-assisted suicide is not a good option without decent, universal health care.
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Costs at for-profit and not-for-profit hospitals.
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HIV/AIDS care calls for reallocation of resources.
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Lessons for the health care industry from America's experience with public utilities.
In the United States, the traditional public utilities, power and telecommunications, along with health care, are being deregulated and becoming increasingly competitive, especially on price. Regulation of the public utilities has occurred for the past century not simply because they have been monopolies, but, more importantly, because they are "industries affected with the public interest," that is industries which: 1. provide an essential service, 2. benefit from public prequisites, and 3. would cause great public harm if mismanaged. Consequently, the presence of competition in these industries does not negate the need for regulation. Regulation of these industries is best understood as being along the three sides of a "triangle of public interests"--quality, public accountability, and universal service. Examples are provided of these types of regulation in power and telecommunications, even in current "deregulatory" legislation. Health care reform activists in the United States have lately paid attention mostly to the first two legs of the triangle; they are encouraged to focus creatively on the third leg--universal health care.
The second phase of priority setting. Israel's basic basket of health services: the importance of being explicitly implicit.
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Study of self-referral factors in the three-level healthcare delivery system, Kashan, Iran, 2000.
INTRODUCTION: In any healthcare system an appropriate structure is essential to operational efficiency. Patients must be able to easily access healthcare workers and/or health centers in their own community. In the first contact with a healthcare practitioner, particularly if that contact is with a GP, 90% of patient needs can be met. If the initial problem cannot be managed, the decision will be made to refer the patient to a specialist. Except in an emergency, all patients should be seen first by a primary healthcare physician who decides whether a referral to secondary care is necessary. This avoids system inefficiencies such as disadvantaged groups suffering from lack of specialist care due to specialist doctors being overwhelmed by the inappropriate self-referrals. In the Kashan region, Islamic Republic of Iran, patients can be classified according to their type of health insurance, which dictates the type of specialist referral available: (1) Closed-loop referral (Imam-Khomeini Welfare Committee); (2) Semi-closed-loop referral (Rural Health System Insurance); and (3) Open referral (social security insurance, therapeutic services insurance, self-insured [private] and the non-insured). The organisation of the Iranian health system has been proposed by WHO as a model for other communities. The present study examined patterns of patient self-referral direct to specialist according to health insurance system in the rural Kashan region, and established the reasons for patient self-referral to specialists. METHODS: A random sample of 1036 individuals was selected from people attending public outpatient clinics and specialists' offices in the private health sector. Of the sample, 413 (40%) were insured by the Imam-Khomeini Welfare Committee (closed loop referral); 145 (14%) by rural health system insurance (semi-closed-loop referral); and 478 (46%) were covered by social security or therapeutic services insurance, out of pocket and other cost payment procedures (open referral). The subjects were interviewed individually in the waiting room by means of a questionnaire before or after their specialist visit. The self-referral rate in the triple insurance structure was calculated. The data were analyzed using a chi2 statistical test. RESULTS: Of the closed-loop referral system patients, 6.8% were self-referred, as were 29.7% of semi-closed referral system patients and 75.5% of open referral system patients (chi2 = 504; p <0.0001). The self-referral rate to the public sector was 60.5%, while to the private sector it was 36.4%, (chi2 = 449; p <0.001). The main reason patients gave for by-passing GPs and self-referring to specialists were: the specialist's high degree of skill in the specific area of the health problem (54%); waste of time to see the GP for a referral (14.9%); and that the patient's information about the referral system was poor (10.5%). CONCLUSION: The findings of this small study demonstrate the high degree of difference in the rates of referral by GP and self-referral according to the healthcare delivery system structure (insurance type and sector). The universal availability of health insurance may be one of the reasons for the similar health status of rural and urban populations in Iran. The findings may be regarded as preliminary to further research into this area of health system design.
Universal access to health care. A comprehensive tax-based approach.
More than 30 million Americans lack health insurance, and millions more are "underinsured." Meanwhile, the cost of health care in the United States is escalating, and some of our care is of questionable value. This article presents a health care reform strategy that addresses these three fundamental problems in the US health care system. The strategy, designed to empower consumers to make cost-conscious health care choices, combines a universal tax credit that enables all Americans to purchase basic health coverage; insurance reforms including pooling and reinsurance mechanisms; requirements that all employers make insurance available to their employees and that all consumers purchase coverage; and efforts to measure and improve the quality and efficiency of health care services. This strategy would help us to achieve universal health insurance coverage, while creating the proper incentives for cost control. In addition, it can be largely internally financed through savings automatically triggered by its implementation.
The Australian health system: continuity and change.
The health of Australians, with the exception of Aboriginals and Torres Strait Islanders, compares favourably with other industrialised nations. Since 1984, universal access for citizens to medical and public hospital services has been achieved under a national Health Insurance Scheme called Medicare, partially funded by a 1.4 percent levy on all taxpayers. Medicare found early widespread support from the electorate but continues to be buffeted by a minority coalition of some medical associations, private health insurers, and conservative "libertarian" politicians. Over the decade since its inception, Medicare has provided stability in maintaining total health costs around 8 percent of GDP. This has been largely due to capping hospital costs via Commonwealth-State agreements. Medicare has failed in the past five years to contain medical costs which have increased proportionally with increases in the medical workforce. This article examines the structure and performance of Medicare and its role within Australia's overall health system. Benefits of a universal access insurance program are outlined together with challenges associated with inequities in health status, geography, aging of the population, burgeoning technology, ideological diversity, and an economic climate requiring cost containment and favouring privatisation and the role of the market. It can be concluded that, despite these challenges, universal access to health care is here to stay. Australia's Medicare program has become popular with the electorate.
The Oregon Health Plan: lessons learned.
The widely publicized Oregon Health Plan (OHP) was established in 1989 to provide the residents of Oregon with universal access to health insurance. The OHP encompassed provisions to reform Medicaid, which included relaxing eligibility requirements and requiring Medicaid beneficiaries to enroll in managed care plans. To date, the OHP has improved access to health care facilitated the efficient use of healthcare services. However, problems with the program exist--failure of Medicaid beneficiaries to choose a health plan and primary care physician, inadequate education of the enrollee population, and frequent enrollee turnover, for example. These problems offer lessons to the rest of the nation as Medicaid managed care plans proliferate.
Universality and medical necessity: statutory and charter remedies to individual claims to Ontario health insurance funding.
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National health insurance in America--can we practice with it? Can we continue to practice without it?
Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.
The Canadian and U.S. health care systems: profiles and policies.
Comparisons are made in this article between the Canadian and U.S. health care insurance and delivery systems. Canada has universal, comprehensive, and publicly funded health insurance for medically necessary hospital and physician services. The United States does not. Aggregate health care expenditures for both countries are examined as are those for the hospital and physician services sectors. Policy differences between both systems, including system models, health insurance financing, resource commitment and control, and service limits, are presented. Observations are made regarding two elements of the Canadian model--prospective physician sector and prospective hospital global budgeting--and whether they are transplantable to the United States.
International symposium on future prospect of health insurance program in developing and developed countries at United Nations University, Tokyo.
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Cost-saving features of universal coverage.
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Oregon's residents to vote on universal health care.
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Is the time finally ripe? Health insurance reforms in the 1990s.
Reformers feel certain that the time is now ripe for progressive legislation to ensure universal citizen access to health insurance and to contain rising costs in the health care industry. But history shows us that reformers were equally confident in earlier periods of modern U.S. history, only to find themselves defeated by conservatives willing to deploy ideological, emotionally charged arguments against government-sponsored reforms. Today's advocates of inside-the-beltway bargains for hammering out compromise reforms may be vulnerable to similar conservative counterattacks. Reformers need to engage the U.S. citizenry as a whole in democratic discussion about the ideals of government-sponsored health care reforms. Advocates of single-payer plans can do this more readily than supporters of complex public-private schemes such as play or pay or managed competition, but all those who want inclusive and effective reforms during the 1990s must face the challenge of democratic dialogue.
National health insurance in the United States: a drama in too many acts.
Responding to the question, "Universal Health Care: How Can We Get There from Here?," this paper describes the history of governmental health insurance in the United States, analyzes the factors that have proved to be crucial to its establishment in other countries, and concludes that without a strong Labor Party, there will be no national health insurance, no universal healthcare system in the United States.