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PubMed1999

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.

Financing, Government↗
PubMed1980

Future directions in national health policy for the United States.

Unlike other countries which have established some form of national health insurance, the United States is debating this profound social program in facing all problems of financing and managing personal health services simultaneously: elimination of cost at time of service, sharing this cost equitably through the tax system, distributing the services equitably goegraphically, controlling rapidly rising costs and managing the organizational structure of services. Originally in other countries the primary objectives were to free citizens of the burden of costly illnesses, improve access across income groups, and share the costs more or less equally. Now other countries are expressing the problems found simultaneously by the United States. It is argued that universal and comprehensive national health insurance spreads money and resources so thinly that specific and important problems such as pockets of high infant mortality or curable diseases are obscured and ignored. The United States sould set up a health program which targets specific problems and mitigates high cost episodes rather than indulge itself in a comprehensive and universal national health insurance. This proposal is not politically feasible, however, and predictions are made as to what will happen in the United States within the politically and culturally determined range of debatable options.

Delivery of Health Care↗
PubMed1992

The practice and ethics of risk-rated health insurance.

Health insurance in the United States is driven by competitive risk rating and is promoted as the best way to give policyholders optimal value for their money and to be fair to those with lower risks. In practice, however, competitive risk rating costs more than noncompetitive, universal systems of health insurance, and it erodes the basic function of insurance to spread infrequent large losses over a wide base. This article describes not only how risk rating covers least those with the greatest medical bills, but also how it has spawned a labyrinth of complex manipulations by insurance companies to charge more or pay less than actuarially fair risk rating would justify. The final section shows that even if risk rating were done fairly, it contradicts moral fairness. Many of the leading proposals for national health insurance do not address these practical and ethical issues. The medical profession and policymakers need to discuss them and take a stand on them.

Actuarial Analysis↗
PubMedDate not supplied

Preventing blindness in Americans: the need for eye health education.

Black Americans are twice as likely to be blind as their white counterparts. Although blindness is preventable or curable in half of the patients studied, we have found that black Americans are only half as likely to be treated for glaucoma or cataract, which are the two leading causes of blindness in this population. Our data show that this treatment gap is not related to the supply of ophthalmologists or the patients' personal income, even among insured populations. In addition to the devastating financial costs incurred by blind individuals and their families, a single year of blindness for a working age American costs the federal government approximately $12,000. Research has shown that preventing blindness is often less expensive, in simple economic terms, than paying for the costs a blind individual incurs. These findings raise important questions about access to care and how it may improve within the context of health care reform. Government surveys show that black Americans, even those with health insurance, are significantly less likely to seek or obtain examination by an ophthalmologist. In studying utilization of care, we found that, in aggregate, black Americans who see an ophthalmologist are as likely as their white counterparts to be treated for glaucoma, cataract, and other blinding diseases. We propose that, beyond universal access to health insurance, eye health education that influences people to see an ophthalmologist may be the single most important step we can take to prevent needless blindness. Not only can education and preventive eye care save needless suffering, it may save scarce federal dollars as well.

Blindness↗
PubMed1993

Physician utilization disparities between the uninsured and insured. Comparisons of the chronically ill, acutely ill, and well nonelderly populations.

BACKGROUND: This study examines the associations between lack of health insurance coverage and physician utilization for the chronically ill, acutely ill, and well nonelderly populations in the United States. METHODS: Cross-sectional data from the 1989 National Health Interview Survey, conducted by the National Center for Health Statistics, were analyzed for the nonelderly population using a correlational, two-group design (N = 102,055). Analytic models, using multiple logistic regression, were tested to predict the odds and likelihood of physician utilization for the uninsured and insured in the three subpopulations (ie, chronically ill, acutely ill, and well), controlling for health status, number of conditions, and geographic, sociodemographic, and economic factors. Disparities in utilization were then calculated between the uninsured and insured for each subpopulation. RESULTS: The nonelderly uninsured were consistently less likely than the insured to have received any health care within 12 months. Moreover, there were differential effects of being uninsured on utilization depending on whether an individual was chronically ill, acutely ill, or well. Whereas chronically ill and well uninsured persons were half as likely to have seen a physician as their insured counterparts (odds ratio, 0.50), acutely ill uninsured persons were almost two thirds as likely to receive physician care (odds ratio, 0.62). Thus, the disparity in physician utilization between the uninsured and insured was larger for the chronically ill and well than for the acutely ill; uninsured acutely ill were less likely to go without care. Of the three populations, those in the well population had average disparities with the largest magnitude (40%), compared with disparities of the chronically ill (20%) and acutely ill (10%). CONCLUSIONS: These disparities represent large inequities in utilization of care by the uninsured, particularly for the chronically ill and well. Whether these disparities result from lower access or individual choice cannot be determined from this study. When viewed in light of other studies examining the impact of utilization on health status, these results provide support for the development of comprehensive health insurance packages with universal coverage and better inclusion of chronic and preventive care models in benefit packages.

Acute Disease↗
PubMed2004

Reforming health care financing in Bulgaria: the population perspective.

Health financing reform in Bulgaria has been characterised by lack of political consensus on reform direction, economic shocks, and, since 1998, steps towards social insurance. As in other eastern European countries, the reform has been driven by an imperative to embrace new ideas modelled on systems elsewhere, but with little attention to whether these reflect popular values. This study explores underlying values, such as views on the role of the state and solidarity, attitudes to, and understanding of compulsory and voluntary insurance, and co-payments. The study identifies general principles (equity, transparency) considered important by the population and practical aspects of implementation of reform. Data were obtained from a representative survey (n=1547) and from 58 in-depth interviews and 6 focus groups with users and health professionals, conducted in 1997 before the actual reform of the health financing system in Bulgaria. A majority supports significant state involvement in health care financing, ranging from providing safety net for the poor, through co-subsidising or regulating the social insurance system, to providing state-financed universal free care (half of all respondents). Collectivist values in Bulgaria remain strong, with support for free access to services regardless of income, age, or health status and progressive funding. There is strong support (especially among the well off) for a social insurance system based on the principle of solidarity and accountability rather than the former tax-based model. The preferred health insurance fund was autonomous, state regulated, financing only health care, and offering optional membership. Voluntary insurance and, less so, co-payments were acceptable if limited to selected services and better off groups. In conclusion, a health financing system under public control that fits well with values and population preferences is likely to improve compliance and be more sustainable. Universal health insurance appears to attract most support, but a broader public debate involving less empowered people is needed to resolve misunderstandings and create realistic expectations.

Adult↗
PubMed1998

[Access to social coverage of uninsured patients attending a hospital clinic: a historical cohort study at the Baudelaire outpatient clinic in Paris].

BACKGROUND: In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays. METHODS: All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling. RESULTS: Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage. CONCLUSIONS: Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.

Adult↗
PubMed1991

Mental health services under a U.S. national health insurance plan.

Sometime during the 1990s, the U.S. Congress could enact legislation that would establish universal access to basic hospital and physician services and, later, create a national health insurance plan. The author explores the potential effect of these programs on state psychiatric facilities; short-term acute psychiatric care facilities, including those under for-profit ownership; mental health professionals; and delivery of patient care. Each year about 63 million uninsured Americans would be eligible for basic health care under a universal access program, and mentally ill patients who are now unable to afford care would then be eligible for limited mental health services. National health insurance, enacted after the universal-access approach fails, is likely to support the current trend of proportionately more ambulatory and less inpatient mental health care. Wealthy Americans are likely to use the national health insurance system but may also use private mental health services, thereby perpetuating the current pluralistic health care delivery system.

Evaluation Studies as Topic↗
PubMed1991

Justice and the market for health insurance.

After reviewing some of the insurance-related obstacles to access to health care, some ethical criteria for evaluating proposals aimed at reforming the health insurance marketplace to achieve universal access are developed. The additional reforms needed to eliminate many of the deficiencies in the current health insurance marketplace are discussed. It is suggested that without such substantial reforms some of the other goals such as expanded consumer choice and overall societal health care cost savings may not be effectively promoted.

Economic Competition↗
PubMed2005

Funding, ethics, and assistive technology: should medical necessity be the criterion by which wheeled mobility equipment is justified?

The article will explore the use of the term medical necessity as it relates to wheeled mobility. Health insurance will cover a wheelchair if it is determined that it is medically necessary for a particular client. There are many different types of health insurance, and no universal definition of medical necessity. This presents a problem for clients and for individuals who are making wheelchair recommendations for clients. Case studies describe how equipment is currently recommended based on the limitations of the client's insurance coverage. As more equipment becomes available to improve the quality of life for people with disabilities, it will become harder for therapists recommending equipment to determine the limits of medical necessity.

Activities of Daily Living↗
PubMed2002

One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?

A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. SHI was first introduced in Germany in 1883. An analysis of the German system from its inception up to today may yield lessons relevant to other countries. Such an analysis, however, is largely lacking, especially with regard to LMICs. This paper attempts to fill this gap. For each of the following lessons, it considers if and under which conditions they may be of relevance to LMICs. First, small, informal, voluntary health insurance schemes may serve as learning models for fund administration and solidarity, but in order to achieve universal coverage government action is needed to formalise these schemes and to introduce a principle of compulsion. Once compulsory health insurance exists for some people, incremental expansion of coverage to other regions and social groups may be feasible to achieve universality. Second, in order to ensure sustainability of SHI, the mandated benefit package should be adapted incrementally in accordance with changing needs, values and economic circumstances. Third. in a pluralistic SHI system equity, as well as risk pooling and spreading, can be enhanced if funds merge. The optimal number of funds, however, will depend on the stage of development of the SHI system as well as on other objectives of the system, including choice and competition. A risk equalisation scheme may prevent the adverse effects of risk selection, if competition between insurance funds is introduced into the system. Fourth, as an alternative to both state and market regulation, self-governance may serve as a source of stability and sustainability as well as a means of decentralising and democratising a health care system. Finally, costs can be successfully contained in a fee-for-service system, if cost-escalating provider behaviour is constrained by either political pressure or technical means.

Developing Countries↗
PubMed2001

Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders.

OBJECTIVE: The aim of this study was, on the basis of data from health-care registers, to describe the adequacy of psychopharmacological treatment in suicides. METHOD: Data on consecutive suicides in a Danish County (Funen) in the period of 1 April 1991-31 December 1995 were identified in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense University Pharmacoepidemiological Database. RESULTS: Twenty-five per cent of the suicides previously hospitalized due to affective disorders and 3% of the suicides without psychiatric hospitalizations at all, received an apparently adequate treatment with antidepressants the month before suicide. CONCLUSION: The most striking finding was the insufficiency of treatment with antidepressants in the group of suicides without psychiatric hospitalization, in particular in light of the fact that depression is assumed to be present in at least 50% of all suicides.

Adult↗
PubMed1991

Health insurance values and implementation in The Netherlands and the Federal Republic of Germany. An alternative path to universal coverage.

The health care systems in the Netherlands and the Federal Republic of Germany are based on a set of values that involve mutual obligations between private parties. These obligations are realized through systems incorporating private practice physicians, community and church- and municipality-affiliated hospitals, and nonprofit and for-profit insurers. The underlying values and implementation approaches in these systems provide an alternative to the adoption of a Canadian-style health insurance system. A discussion that focuses on "obligations" rather than "rights" may be a more useful approach for the design of reforms of the American health system in the 1990s. Such a discussion would focus on the mutual responsibility of all parties to create and maintain a universal private health care system.

Germany, West↗
PubMed2003

New options for health care policy and health status insurance: citizens as customers.

Health education and health literacy programs have implications on health care policy and health care status insurance. There are many benefits of a transition from disease management to a health care system, which includes priorities in prediction, prevention, and health education. Health care and disease management could best be implemented by multiple-tier, market-oriented models of universal coverage allowing for competition among health status insurers and educational, pharmaceutical, nursing, and other health service providers. Promotion of health literacy will allow citizens to become educated customers and consumers of health care services. Internationally, health literacy might narrow the gap between economically richer and poorer countries.

Delivery of Health Care↗
PubMed2004

Why the United States has no national health insurance: stakeholder mobilization against the welfare state, 1945--1996.

The United States is the only western industrialized nation that fails to provide universal coverage and the only nation where health care for the majority of the population is financed by for-profit, minimally regulated private insurance companies. These arrangements leave one-sixth of the population uninsured at any given time, and they leave others at risk of losing insurance as a result of normal life course events. Political theorists of the welfare state usually attribute the failure of national health insurance in the United States to broader forces of American political development, but they ignore the distinctive character of the health care financing arrangements that do exist. Medical sociologists emphasize the way that physicians parlayed their professional expertise into legal, institutional, and economic power but not the way this power was asserted in the political arena. This paper proposes a theory of stakeholder mobilization as the primary obstacle to national health insurance. The evidence supports the argument that powerful stakeholder groups, first the American Medical Association, then organizations of insurance companies and employer groups, have been able to defeat every effort to enact national health insurance across an entire century because they had superior resources and an organizational structure that closely mirrored the federated arrangements of the American state. The exception occurred when the AFL-CIO, with its national leadership, state federations and union locals, mobilized on behalf of Medicare.

Health Benefit Plans, Employee↗
PubMed2001

Health status of African Americans.

The health status of African Americans identifies a higher prevalence of cardiovascular diseases, cancer, hypertension, diabetes, obesity, and sexually transmitted infections when compared with Whites. However, more research is needed to identify socioeconomic variables and to establish needed health programs. The vestiges of early 20th century traditions of substandard housing and inadequate nutrition for African Americans are still apparent in many communities today. Most health care professionals are not educated and trained to be culturally sensitive. The struggle against the prevalence of diseases in African Americans must incorporate cultural sensitivity, community organization and empowerment. The need for a universal system of health insurance coverage is of utmost importance. The elimination of health disparities among African Americans requires a national effort, the involvement of public and private sectors, individuals and communities.

Black or African American↗