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In early 1991, former Massachusetts Gov. Michael Dukakis spent three months at the University of Hawaii School of Public Health studying the state's unique system of health insurance. Recently he talked with JAHP Editor in Chief Richard Sorian about the lessons he learned from looking at Hawaii's "universal health coverage" and why the experience was different in his home state.
The Japanese health care system is sometimes considered one of the best in the world because it appears to have achieved universal coverage, high quality, and a comparatively low level of expenditure. But under compulsory national health insurance and the uniform fee schedule which has worked well so far, various problems have been produced in Japan. A growing number of persons believe some reform or readjustment may be required. Following a brief review of the Japanese health care system which includes health insurance mechanisms, the relationship among physicians, hospitals and clinics, and the impact of these structures on access to care are explored. The resulting cost of care and the quality of care are then addressed. The lack of consumer information and the nature of the physician-patient relationship related to cultural factors are important components of this health care system. These latter factors are in the process of change and the likely direction of their influence upon the Japanese health care system is explored.
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AIM: To estimate the likely cost to the New Zealand Government of providing universally free primary medical care. METHODS: Estimates of current government expenditure on various categories of health were obtained from Ministry of Health sources. Information from the Rand Health Insurance Experiment was used to estimate the changes in demand for general practitioner (GP) visits, pharmaceutical, laboratory and other referred services, and hospital services. The effects of a supplier response and complement (pharmaceutical) prices were also considered. RESULTS: Assuming that GPs act to control their patients' increasing demand for services, providing free primary care to all New Zealanders is likely to cost the Government between 435 million dollars and 592 million dollars (based upon 1998/99 year data). CONCLUSIONS: The difficulties and likely inexactness in making estimates of this sort are acknowledged; however, when considering such important changes in health policy, it is important to attempt to define likely costs (and benefits). Consideration of costs must go beyond simply estimating current private expenditure on primary medical care.
As epidemiological data concerning varicella in Germany were not available, a retrospective study was conducted to investigate the impact of the disease, focusing also on economic aspects. A representative German-wide sample of 1334 unvaccinated varicella cases was obtained in 1999 from randomly selected paediatric (P) and general, as well as internal, mainly adult (A), practices. Following representative weighting, the median age was 5 years, with 90% of cases aged < 12 years. The highest incidence was in children aged 5-6 years. Varicella-related complications occurred in 5.7% of patients, and accounted for 0.1 hospital days/case on average. Certificates of sick leave were issued for 1.3 sick days/case, with 0.6 days paid by health insurance funds to parents caring for their sick child, and 0.7 days paid by the employer. With an annual incidence of 760,000 diagnosed cases in Germany for the year 1999, this amounts to an annual cost of c.150 million Euro, with c. 50 million Euro paid by the statutory health insurance system. It was concluded that universal varicella vaccination in Germany would provide essential clinical improvements for patients and prevent hospital admissions. In addition, significant economic benefits can be expected, mainly because of the high level of indirect health costs in Germany.
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.
Increasing health care costs are forcing collegiate institutions to find more economical ways to meet the health care needs of students. Student health insurance programs are a major component in meeting these needs. This national survey reports the extent to which student health insurance programs are offered or administered by 2-year and 4-year colleges, universities, and professional and graduate schools in both the public and private sectors. The study finds that most programs are optional, open to all registered students regardless of age or credit load, with dependent coverage options usually available. Reported enrollment levels suggest that less than 20% of the students participate at a majority of the institutions surveyed. Concern about group health insurance at the collegiate level reflects national concern over the large number of Americans who currently lack health coverage.
OBJECTIVES: Universal coverage will trigger an increase in health-care spending, because the uninsured will use more services after they are insured. The effect of insurance status on expenditures is estimated here from a multivariate statistical model. METHODS: The model is estimated with data from the 1987 National Medical Expenditure Survey, aged to 1994 using population projections from the US Bureau of the Census and expenditure projections from the Health Care Financing Administration. RESULTS: Expenditures for the full-year uninsured increase by approximately $700 per person in 1994 as a result of universal coverage. Nearly half of the increase is because of a substantial increase in the likelihood of hospitalization. CONCLUSIONS: If the uninsured are enrolled in plans similar to those offered by employers currently, personal health-care spending increases by approximately $20 billion in 1994. There are other costs associated with universal coverage that are not included in this figure.
OBJECTIVE: To examine the relation between continuity of care and preventive health care and emergency department (ED) use in a universal health care system. DATA SOURCES/STUDY SETTING: Administrative data that capture health care use of the entire population of a midwestern Canadian city. STUDY DESIGN: A population-based, retrospective study of all individuals who had a least one physician contact in 1998 or 1999 (total N=536,893). METHODS: Logistic regressions were conducted to examine the relation between continuity of care, defined in terms of the proportion of total visits to family physicians (FPs) made to the same FP, and cervical cancer screening, breast cancer screening, influenza vaccination, pneumococcal vaccination, and ED visits, controlling for demographic variables, socioeconomic status (defined in terms of relative affluence of neighborhood of residence), and health status. PRINCIPAL FINDINGS: Continuity of care was related to better preventive health care and reduced ED use. A consistent socioeconomic gradient also emerged. For instance, the odds of having a mammogram was double for individuals living in the wealthiest neighborhoods, relative to those in the poorest neighborhoods (adjusted odds ratio=2.31, 99 percent CI 2.13-2.50). CONCLUSIONS: Having a long-term relationship with a single physician makes a difference even in a universal health care system. Moreover, socioeconomic disparities remain, suggesting the need to target specifically individuals from lower socioeconomic strata for preventive health care.
OBJECTIVE: To study the gatekeeper function of Dutch general practitioners (GPs) by investigating the relation between the referring GP, referrals, and referral cards. (In the Netherlands, it is customary that patients only see a specialist after referral by their GP. In this way the GP acts as a gatekeeper between primary and secondary care. Specialists are paid by the patient's insurance company which they send a so-called referral card stating the name of the referring GP.) DESIGN: Descriptive. SETTING: Hospitals in Groningen and Hoogeveen and four general practices in the area. METHOD: The study questions were answered using data for 1993 of the computerized morbidity Registration Network Groningen (RNG) of the Department of Family Medicine of Groningen University and data of two regional health insurance companies (RZG and Het Groene Land). RESULTS: For 1993 the RNG showed a referral-referral card ratio of 34%, ranging from 24% to 42% among different practices; and from 17-46% among the various specialties. For the surgical specialties, the range of indications for which patients were actively referred to the various specialties varied from 21-33 per 100 referrals, for the non-surgical specialties it ranged from 25 to 56 per 100 referrals. The number of referrals by the 'own' GP accounted for an average of three-quarters of the referral cards attributed to the own GP. The last five years the number of referrals varied showing no clear increase or decrease. DISCUSSION: GPs appeared to have difficulty in acting as gatekeeper once patients were being treated by the specialist. In studies of referrals. research into specialists' follow-up strategies should be an integral part. A back referral or return card could facilitate this type of study.
The Health Insurance Portability and Accountability Act has mandated the assignment of a universal individual health identifier in 2003. Such an identifier can increase patient confidentiality, improve patient care, lower the cost of services to the patient, enhance administrative efficiency, and increase the opportunity for medical research. Nevertheless, national identification systems raise concerns about confidentiality and privacy. Instead of a mandatory, government-assigned number, this article proposes a technologically multi-tiered system that would be administered by a mixed government and private entity. Consumers could voluntarily opt-in to the system.
This report presents information on the state of the U.S. health sector in late 2004. It includes data on the uninsured and underinsured and their access to health care, underinsurance for long-term care and mental health, and the rising costs of health insurance and health care. The author presents data on the increasing social inequalities in health and access to health care; the role of corporate money in health and health care; and the hospital and pharmaceutical industries. The article also includes updates on the consequences of the Medicare prescription drug bill and the state of Medicare spending, and seniors' spending, on drugs; the results of some recent public opinion polls on health care; information on labor, labor unions, and health insurance; and some international comparisons of health insurance. The article concludes with some useful sources of information on single-payer, universal health care.
OBJECTIVE: To determine whether length of stay (LOS) for asthma admissions at a local university-affiliated children's hospital (UACH) is similar to that of community hospitals within the same county. METHODS: A retrospective analysis was performed using computerized hospital abstract records from 1989 through 1994. The study population was children 1 to 18 years old whose first or only hospitalization for a primary diagnosis of asthma occurred during the study period at either the UACH or one of the 17 community hospitals in King County, WA, that admit pediatric patients (n = 2491). Transfers and patients with chronic obstructive asthma or secondary diagnoses such as cystic fibrosis were not included in the study. Asthma patients were compared by sociodemographic and health risk characteristics such as age, sex, insurance status, and a comorbidity severity score. Differences between the two hospital populations were tested by chi2 and t tests. The effect of hospitalization at the UACH or the community hospitals on LOS was determined using analysis of covariance after adjusting for the sociodemographic and health risk covariates. RESULTS: Sixty-two percent (62%) of the asthma patients in the study population were discharged from the UACH. Compared with patients discharged from the community hospitals, the UACH patients were significantly younger, more often male, used public insurance, and resided in areas with lower median household incomes. The severity of comorbidities was not different between the two hospital groups. Overall, adjusted mean LOS was not significantly longer at the UACH (2.1 days) than at the community hospitals (2.0 days); however, adjusted mean LOS for specific subgroups, most notably poor children and those with public insurance, was significantly longer at the UACH. CONCLUSION: LOS for first or only asthma hospitalizations during 1989 through 1994 at the UACH was similar to local community hospitals within the same county. Specific subgroups of children were hospitalized for a longer period at the UACH, but children with private insurance and from areas with higher median household incomes had similar LOS, and presumably costs, at the UACH and the community hospitals.
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This report provides nationwide and state-specific estimates of U.S. health care administration spending and potential savings in 2003 were the United States to institute a Canadian-style national health insurance system. The United States wastes more on health care bureaucracy than it would cost to provide health care to all its uninsured. Administrative expenses will consume at least dollar 399.4 billion of a total health expenditure of dollar 1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately dollar 286.0 billion in 2003, dollar 6,940 for each of the 41.2 million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage. The cost of excess health bureaucracy in individual states is equally striking. For example, Massachusetts, with 560,000 uninsured state residents, could save about dollar 8,556 million in 2003 (dollar 16,453 per uninsured resident of that state) if it streamlined administration to Canadian levels. New Mexico, with 373,000 uninsured, could save dollar 1,500 million on health bureaucracy (dollar 4,022 per uninsured resident). Only a single-payer national health insurance system could garner these massive administrative savings, allowing universal coverage without any increase in total health spending. Because incremental reforms necessarily preserve the current fragmented and duplicative payment structure, they cannot achieve significant bureaucratic savings.
This study examined the relationship between concern for health insurance coverage and employment status following renal transplantation. The sample consisted of 293 individuals who underwent renal transplantation at The Ohio State University Medical Center. The study found fewer individuals reported employment during the past year (58%) than indicated they were able to work (72%). Although 72% of the sample indicated the physical ability to work 41% reported receiving a monthly disability check. Regression analysis revealed that receipt of a monthly disability check and employment status one day prior to transplant were the two most significant predictor variables for employment activity during the year prior to participation in this study. Intervention that is coordinated on a psychosocial level from the time of diagnosis of ESRD throughout the post-transplant period is critical to supporting individuals in pursuing their goals. Research findings should be utilized to advise policy-makers and advocate for system changes that support employment for individuals with ESRD.
Despite conventional wisdom that southern states have neither the money nor popular support for such a program, a Georgia group has outlined a universal, comprehensive, single-payer proposal called "Georgia SecureCare." The group's telephone survey in 2003 found that a majority of households was concerned about losing health insurance or access. Economic analyses demonstrated that SecureCare would reduce statewide health care spending by dollar 0.72 billion (approximately 2%) in the first year while providing all Georgia residents with a generous benefit package. Despite initial increased healthcare utilization costing about dollar 3.84 billion, notable savings were attributable to lower annual administrative costs (dollar 3.82 billion) and bulk purchasing (dollar 0.74 billion saved for prescription drugs and durable medical equipment). For most families and for large employers, annual expenditures for health would decline. Georgia respondents to the telephone survey initially expressed approximately 72% support for SecureCare. After furnishing them with common objections to the plan, their support dropped to approximately 62%. A universal, state-sponsored plan would likely save money for Georgia, and it could easily win broad-based popular support.