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PubMed1993

Universal access to health care: a practical perspective.

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)

Community Participation↗
PubMed1999

Employment-based health insurance: a look at tax issues and public opinion.

This Issue Brief provides background information on the employment-based health insurance system and its alternatives. The report discusses the advantages and disadvantages of the current employment-based health insurance system, the current tax treatment of health insurance, and the strength and weaknesses of recent proposals to introduce tax credits. It presents findings from the public opinion survey conducted by the Employee Benefit Research Institute on public attitudes toward health insurance and summarizes recent research on the effects of tax changes on employment-based health benefits and the uninsured. Employment-based health plans are the most common source of health insurance among nonelderly individuals in the United States, providing coverage to nearly two-thirds of this population in 1997. Health insurance is probably the benefit most used and valued by workers and their families. Sixty-four percent of respondents to a recent survey rated employment-based health insurance benefits as the most important benefit. Despite essentially five years of very low health care cost increases and the recent increase in the percentage of Americans with employment-based health insurance coverage, the uninsured population has continued to rise. This has resulted in a new interest among policymakers in finding ways to reverse this trend. One question that continues to be asked is whether the employment-based health insurance system is the appropriate mechanism for expanding health insurance to the uninsured. Employment-based health plans are popular because they offer many advantages over other forms of health insurance and types of delivery systems. However, there are also potential drawbacks to the employment-based system. The advantages include reduced risk of adverse selection, group-purchasing efficiencies, employers acting as a workers' advocate, delivery innovation, and health care quality. The disadvantages include an unfair tax treatment, lack of portability and job lock, little choice of health plans, and lack of universal coverage. The tax credit proposals for health insurance, which come in all shapes and sizes, would either enhance the current employment-based health insurance system or put it at risk. This has potentially enormous public policy implications, since the vast majority of Americans get their health insurance coverage through employers. Such a change may also have political implications, as public opinion currently may not support such a fundamental change in the U.S. health insurance system. A recent public opinion survey conducted by the Employee Benefit Research Institute found that 68 percent of Americans with employment-based health insurance were satisfied with the current mix of benefits and wages. The EBRI survey found that under a changing tax code scenario, there is still strong support for the employment-based system. Strong support for the employment-based system may be the result of respondents' lack of confidence in their ability to choose the best health plan if their employer stopped offering health insurance.

Data Collection↗
PubMed2004

A government sponsored clinic for the evaluation and treatment of chronic hepatitis C in an underinsured population in Puerto Rico.

BACKGROUND: Chronic hepatitis C (CHC) is a major health problem in Puerto Rico (PR). More than 50% of the population is insured by a government-sponsored managed care system that does not cover treatment for CHC. Lack of access to treatment will result in an increase in end-stage liver disease with its high socioeconomic impact in the future. In an attempt to identify strategies for the treatment of CHC in the publicly insured population, the PR Health Department and the University of Puerto Rico (UPR) Gastroenterology (GI) Division have developed a pilot clinic for the evaluation and treatment of CHC. METHODS: UPR and the PR Health Department negotiated a fee per patient to include all medical care and follow-up laboratories. Viral studies were covered by a grant to the Health Department. Medications were bought at a discount price by the government and dispensed at a government pharmacy. The Health Department allocated funds for 200 patients with government insurance. A dedicated clinic was established at the UPR, staffed by an internist under the supervision of the GI faculty. Patients with a positive HCVab were referred to this clinic. The public insurance covered the CBC, liver tests, metabolic panel, TSH, HBsAg, HIV, ultrasound and liver biopsy, which were required prior to evaluation for possible treatment. In the initial visit, patients underwent a medical evaluation, including assessment of suitability for therapy and counseling. Those deemed to be candidates who still needed a liver biopsy had it performed by the GI staff. Genotype and viral titers were ordered after the decision on treatment had been made. The clinic physician prescribed pegylated interferon and ribavirin, which were dispensed by the government pharmacy. Instruction on proper drug administration was given. Clinic visits were scheduled for 1, 3, 6 and 12 months but also allowed on demand. Laboratory tests were done at the clinic and reviewed by the physician expediently to monitor for toxicity. Any medical problems or treatment for complications of therapy were covered by the primary insurer. Viral load was repeated at 12 weeks to discontinue therapy in those unlikely to respond. The budget per patient for medical visits and laboratory tests was dollars 1,500.00, HCV RNA titers plus genotype costs dollars 200.00, and HCV qualitative RNA costs dollars 123.00 RESULTS: 405 patients have been referred between February 2002 and April 2003 (the number was increased at adjust for no-shows and those not treated). 30% are female, the major risk factor is IVDU, and 80% are unemployed. 101 have started treatment and 48 are awaiting biopsy. A support group has been established at the clinic. CONCLUSIONS: The treatment for CHC in practice is not only costly but also resource consuming. Most gastroenterologists in our community refer these patients for treatment. The establishment of a dedicated clinic with a primary physician supervised by the specialists reduces costs and facilitates caring for a larger number of patients. The volume of services allows for negotiation of medical, laboratory and drug costs. In allocating funds for this project, the PR Health Department recognized the importance in reducing the potential spread in the community by treating infected patients as well as reducing the future medical and socioeconomic burden of end-stage liver disease. Although the outcome of this project is still unseen, we believe that this model may serve to establish other clinics for the treatment of CHC at lower costs with the same effectiveness.

Adult↗
PubMed1989

Taking care of Canada. Part I.

As America agonizes about soaring medical costs and the millions who lack health insurance, Canada's system illustrates the prospects and pitfalls of universal coverage.

Canada↗
PubMed1995

Health insurance status and the use of emergency and other outpatient services by adults with sickle cell disease.

STUDY OBJECTIVE: To evaluate insurance status and frequency of use of emergency services in adults with sickle cell disease. DESIGN: Retrospective analysis of visits. SETTING: Emergency department and outpatient clinics of an urban university hospital. PARTICIPANTS: One hundred seventy-two subjects, who made 771 visits to the ED during 1990. RESULTS: Of the 172 subjects, 31 were covered by commercial insurance, 32 were covered by Medicare, and 109 were covered by Medicaid or were uninsured. Insurance status and frequency of use of emergency services were independent (P > .05). On discriminant analysis, Medicaid-covered and uninsured subjects were correctly classified, but commercially insured and Medicare subjects were not. Medicaid and uninsured subjects were more likely to be younger and to live closer to the hospital (P < .00005). High-frequency users of emergency services were discriminated from low-frequency users. High-frequency users were more likely to be younger, to be users of primary-care services, and to live closer to the hospital (P = .0004). CONCLUSION: Provision of primary-care services or stable insurance in the form of commercial insurance or Medicare did not decrease use of emergency services in subjects with sickle cell disease in a group of patients selected from one urban academic ED.

Adult↗
PubMedDate not supplied

Stanford University's experience with managed competition.

Stanford University has a "managed competition" model of health insurance. Stanford contributes the cost of the low-cost plan, and employees are responsible for premium differences between this plan and other offerings. Each employee gets what he or she wants and is willing to pay for, and everyone has low-cost access to health insurance. Stanford risk-adjusts the premiums based on age and sex and plans soon to adjust including prescription drug data. In the past five years, premiums have risen rapidly, in line with the rest of the market. For competition to transform the delivery system, most employers in the region must adopt managed competition.

California↗
PubMed1998

[The French health care system and its reform].

The French health care system is characterized by its social insurance scheme with universal coverage, freedom of prescription and of location by the doctor, fee-for-service payment by patients, and free choice of doctor by patients, which essentially tends to inflate its health expenditures. Thus, the health expenditures of France has been increasing over the average expenditures of other European countries. Under the principle of autonomy of the social insurance fund, the increase in medical expenditures has been absorbed by a decrease in the reimbursement rate and an increase in the contribution rate of the insured. However, it is no longer possible to cope with this financial crisis by these traditional measures because of the worsening of the unemployment problem. Nowadays, the increase in the contribution rate is regarded as one of the important reasons for the economic stagnation of the French society. In order to cope with this difficult situation, the French government has changed its health policy from the demand side strategy to the supply side strategy. The concrete plan of this policy was presented by Prime Minister Alain Juppé (the Juppé plan). The plan consists of; 1) unification of the medical insurance scheme, 2) establishment of a ceiling on medical expenditures, 3) regionalization of health policy, 4) disclosure of medical information, 5) introduction of medical references, 6) creation of a social protection scheme for the dependent elderly, 7) introduction of an object tax for the social security fund, etc. These subjects have been materializing step by step after many twists and turn. The most important principles of the plan are the transparency of the medical information and the responsibility of each actor within the health system. The French government has conducted a lot of international comparable studies of health systems. According to the results of a series of active and profound discussions, the French government has conducted various social experiments. It is very meaningful for the Japanese government to analyze this process of health reform occurring in France in order to discuss the health system reforms in Japan.

Delivery of Health Care↗
PubMed2005

Key performance indicators for the implementation of social health insurance.

Several low- and middle-income countries are interested in extending their existing health insurance for specific groups to eventually cover their entire populations. For those countries interested in such an extension, it is important to understand what characterises a well performing social health insurance scheme. This article provides a simple framework to analyse key performance issues related to the functions of health financing within the context of social health insurance. The framework first illustrates how performance in the health financing functions of revenue collection, pooling and purchasing affects the realisation of health financing targets of resource generation, optimal resource use and financial accessibility of health services for all. Then, within each health financing function, key performance issues and associated measurable indicators are developed. The set of performance indicators provided in this article should help policy makers to monitor the development of social health insurance schemes and identify areas for improvement. In doing so, policy makers can come closer to achieving universal coverage -- access to appropriate healthcare for all at an affordable cost -- the ultimate goal of social health insurance.

Developing Countries↗
PubMed2004

Why it is time to review the role of private health insurance in Australia.

The role of private health insurance (PHI) within the Australian health-care system is urgently in need of comprehensive review. Two decades of universal health cover under Medicare have meant a change in the function of PHI, which is not reflected in policies to support PHI nor in the public debate around PHI. There is increasing evidence that the series of policy adjustments introduced to support PHI have served to undermine rather than promote the efficiency and equity of Australia's health care system. While support for PHI has been justified to 'take pressure off the public hospital system' and to facilitate choice of insurer and private provider', and the incentives have indeed increased PHI membership, this increase comes at a high cost relative to benefits achieved. The redirection of hospital admissions from the public to private hospitals is small, with a value considerably less than 25% of the cost of the policies. The Commonwealth share of the health care budget has increased and the relative contribution from private health insurance is lower in 2001-02, despite an increase in PHI membership to nearly 45% of the population, compared with the 30% coverage in 1998. The policies have largely directed subsidies to those on higher incomes who are more likely to take out PHI, and to private insurance companies, private hospitals and medical specialists. Ad hoc policy adjustments need to be replaced by a coherent policy towards PHI, one that recognises the fundamental change in its role and significance in the context of universal health coverage.

Australia↗
PubMed1981

Price and membership in a prepaid group medical practice.

Federal interest in prepaid group practices as a means to control rising health care costs in reviving. This article is an empirical study of price and membership at a prepaid group practice among employees of Yale University. This article is the first to estimate the effect of price on the decision for membership in a prepaid group. The probability of joining the prepaid group is estimated to be a function of the relative price of the prepaid group and a conventional third-party insurance plan, the distance of residence to the prepaid group, the perceived quality of services at the prepaid group and the demand for medical services. Our most important finding is that employees' choice is quite sensitive to the relative price of the two plans. This has important implications for federal policy toward prepaid group practices.

Blue Cross Blue Shield Insurance Plans↗
PubMed2005

Relationships among work climate, absenteeism, and salary insurance in teaching hospitals.

This two-tier study, involving employees at a university health centre, explored the relationship between work climate and absenteeism, and also looked at the relationship between work climate and salary insurance. Study findings show that the more positive the perception of work climate, the less employees have the tendency to stay away from work or to stay longer on salary insurance. Regression analyses showed that absenteeism can be predicted significantly by specific work climate indicators such as "challenge," "conflict," and "cooperation." Also, the length of time receiving salary insurance benefits can be predicted by the indicators "trust and support" and "warmth."

Absenteeism↗
PubMed1996

[Health care reform in Chile].

This is a document presented to the Chilean Academy of Medicine by the Health Minister, the economist Carlos Massad, First of all, he refers to the general context of the reform, that he considers a process and not a breakpoint. Afterwards, he enumerates the change task: a) to generate awareness of the change and to convert health in a State issue; b) to adequate programs to population's new health profile; c) to install new management instruments in the health system; d) to decentralize decisions and to promote the participation of beneficiaries; e) to establish incentives and to flexibilize the Health System and f) to introduce correctives to private health insurance. He believes that Chile must drift to a economical protection system for universal and solidary health events. The additional assurances that people wants to buy, must be delimited.

Chile↗
PubMed2004

Community-based newborn hearing screening program in Taiwan.

OBJECTIVE: Congenital bilateral hearing impairment occurs in approximately 1 in every 1000 live births. Universal newborn hearing screening (UNHS) programs are the most effective method for early diagnosis. Previously, newborn hearing screenings in Taiwan were often hospital-based. Our study is a community-based program designed to test the feasibility of performing neonatal hearing screening with a pay-for-test model, and to evaluate its acceptability to parents. METHODS: From March 2000 to December 2002, two hospitals and four obstetric clinics in Tainan city participated in this study. The subjects were healthy newborns whose parents agreed to pay for otoacoustic emissions (OAE) hearing screening. They were tested in the newborn nursery before discharge. The protocol used an initial transient evoked otoacoustic emissions screening followed by a diagnostic auditory brainstem response (ABR) test. RESULTS: A total of 10,008 healthy neonates were recruited, and 5938 newborns (59.3%) were tested. Prior to hospital discharge, 5403 of the newborns (91.0%) had passed the transient evoked otoacoustic emissions test. Referral for further testing was made in 9.0% of cases (535/5938). There were 140 babies lost to 1-month follow up. Only 395 infants (73.8%) of the infants that failed their first otoacoustic emissions tests underwent a second session at the outpatient clinic, and 91 babies failed. They were referred for further auditory brainstem response testing. Ultimately, nine babies were diagnosed with sensorineural hearing loss (SNHL). CONCLUSIONS: There are difficulties in performing universal newborn hearing screening within Taiwan's health insurance system. This study was performed with the cooperation of hospitals and obstetric clinics, and was undertaken with a pay-for-screening model. Our program, with a pay-for-test model, of newborn hearing screening is feasible and was well regarded by parents in Tainan city. It could be run without the government's financial support.

Community Health Services↗
PubMed1986

The health insurance plight of patients with sickle cell disease.

Despite chronic illness that requires routine medical follow-up as well as occasional acute care and hospitalizations, many persons with sickle cell disease (SCD) are not getting the care that they need. The primary reason for lack of proper care is due to the patients' lack of health insurance coverage. This paper will examine the problem of health insurance coverage among persons with chronic illnesses using SCD as a model. It is speculated by the author that persons who suffer from other chronic illnesses may also experience similar problems in obtaining health coverage. Supporting data for this report are derived from a survey on the health insurance status of a randomly selected group of SCD patients treated at the Howard University Center for Sickle Cell Disease. This survey revealed that 20 percent of 70 adult and pediatric patient respondents had no form of health insurance coverage.

Adolescent↗
PubMed1997

Absence of health insurance is associated with decreased life expectancy in patients with cystic fibrosis.

Life expectancy for individuals with cystic fibrosis (CF) has increased dramatically in the last 30 yr, but it is unclear whether the improved survival has applied equally to individuals with different health insurance status. We developed a retrospective inception cohort of all 189 patients with CF born 1/1/55 to 12/31/70 who had at least one hospitalization at a university referral center. The median survival for patients with CF who were without health insurance was 6.1 yr compared with 20.5 yr for those with Medicaid and 20.5 yr for those with private insurance. Using multivariate Cox regression, health insurance and increased socioeconomic status were independently associated with longer survival. The adjusted relative risk of death was greater for the absence of health insurance than for factors previously shown to predict mortality in individuals with CF (female sex and presentation with meconium ileus). In summary, the absence of health insurance was associated with increased mortality rate in children with CF and was a stronger predictor of mortality than variables previously shown to be associated with mortality for CF. If increasing numbers of children with CF lose health insurance coverage, our results suggest that their life expectancy will decrease dramatically.

Adult↗