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PubMed1992

Financing universal health insurance: taxes, premiums, and the lessons of social insurance.

In a society with strong antitax sentiment and large government deficits, the enactment of universal health insurance is blocked by an impasse over financing. The two chief mechanisms for funding universal health insurance are taxes and insurance premiums. Taxes and premiums are not distinct entities; rather, a spectrum of financing methods exists with varying tax-like and premium-like features. Premium-like financing tends to be voluntary and earmarked for health care, with coverage contingent upon making payments and payments going to private insurance firms. Tax-like financing, in contrast, tends to be mandatory and not earmarked for health care, with coverage not dependent upon making payments and payments going to governments. Over the past century, most industrialized nations have developed highly popular social insurance programs to cover periods of retirement, disability, unemployment, and payment for medical care. Social insurance constitutes a blend of tax-like and premium-like features, offering lessons that might assist in breaking the current impasse over universal health insurance financing.

Fees and Charges↗
PubMed1989

The emergence of a health insurance system in a developing country: the case of South Korea.

In an attempt to understand the social forces and the economic and political conditions under which new social policies emerge in developing countries, this study outlines factors affecting the introduction of the health insurance system in South Korea. The emergence of the South Korean health insurance system was influenced by changing labor needs of the industrial sector, increasing social expectations, external and international pressures, increasing medical costs, and class conflict. These pressures compelled the South Korean government to respond to demands for the introduction of new social welfare policies in the 1970s. In the case of South Korea, the new health insurance system resulted from the government's attempts to cope with political, economic, and social pressures rather than from an ideological commitment to the well-being of the population. The resulting insurance system was a way to maintain the social order and legitimacy of the regime, and a means to promote the health of groups important to defense or production.

Humans↗
PubMed1996

Health insurance for kidney donors: how easy is it to obtain?

Because there is a severe shortage of cadaver organs, living donors are a valuable source of kidneys for patients with end-stage renal disease. One area of concern to many potential donors is their ability to obtain health insurance after donation. To investigate this issue, we surveyed 99 health insurance organizations in the United States, including the 10 largest health maintenance organizations, asking for their views and practices regarding living kidney donors; 44% of these organizations responded. The responses were strikingly uniform and indicate that healthy kidney donors should be able to obtain and maintain health insurance at standard rates. This information should be reassuring for concerned people who are considering donating a kidney.

Humans↗
PubMed2002

Health insurer monopsony power: the all-or-none model.

The textbook model of monopsony that is typically employed in analyzing health insurer monopsony power does not adequately describe the supply decision of physicians confronting a dominant health insurer. Rather than restricting purchases in order to extract a lower price for provider services, monopsonistic insurers are able to obtain discounts from providers without experiencing a decrease in quantity when physicians are forced to operate along their "all-or-none" supply curve. The welfare effects of the all-or-none model of monopsony are compared to those implied by the traditional model.

Antitrust Laws↗
PubMed1992

Health insurance in developing countries: lessons from experience.

Many developing countries are currently considering the possibility of introducing compulsory health insurance schemes. One reason is to attract more resources to the health sector. If those who, together with their employers, can pay for their health services and are made to do so by insurance, the limited tax funds can be concentrated on providing services for fewer people and thus improve coverage and raise standards. A second reason is dissatisfaction with existing services in which staff motivation is poor, resources are not used to best advantage and patients are not treated with sufficient courtesy and respect. This article describes the historical experience of the developed countries in introducing and steadily expanding the coverage of health insurance, sets out the consensus which has developed about health insurance (at least in Western European countries) and describes the different forms which health insurance can take. The aim is to bring out the advantages and disadvantages of different approaches from this experience, to set out the options for developing countries and to give warnings about the dangers of some approaches.

Contract Services↗
PubMedDate not supplied

Effects of "second generation" small group health insurance market reforms, 1993 to 1997.

In the mid-1990s, several state legislatures enacted a "second generation" of small group health insurance reforms that required guaranteed issue of all products and prohibited the use of health as a rating factor. We use data from two large employer surveys to compare the behavior of small business in nine states that adopted these reforms between 1993 and 1997 to the behavior of small business in 11 states and the District of Columbia, where neither of these small group health insurance market reforms existed prior to 1997 (N = 8,465 in 1993; N = 12,219 in 1997). Our analyses focus on several outcomes: health insurance offer and enrollment rates in any employer plan, and in an HMO plan; turnover in offer decisions; and premiums, variability in premiums, and the rate of change in premiums. Overall, we find no effect of small group reform on any of the outcomes; the sign of the effect is not consistent across reform states, the estimates rarely attain statistical significance, and they show no consistent pattern across the outcomes within each state. Therefore, predictions of the harm these regulations might cause to the market have not come to pass. On the other hand, proponents' hopes for a solution to low coverage rates among small businesses have not materialized either.

Fees and Charges↗
PubMed2003

Public sector health insurance trusts.

Public sector associations have successfully developed and run employee health insurance pools for almost 30 years, providing members with savings and flexibility not available from commercial health insurance carriers. This article looks at the models, technical tools and governance philosophy that have contributed to their success in a very challenging business environment.

Actuarial Analysis↗
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↗
PubMed1999

Towards a reinforced agency role of health insurers in Belgium and The Netherlands.

This article describes some recent developments in health insurance in Belgium and the Netherlands. Both countries are moving towards greater financial responsibility of health insurers by means of risk-adjusted capitation payment systems. Although for the unwary observer it would appear as if both countries were following similar paths towards a common model, the authors make clear that rather different underlying rationales are driving these trends. In the Netherlands, the grand design 'Dekker proposal' for regulated competition has been replaced by a more gradual implementation of reforms with more limited scope. The ultimate goal remains a system of managed competition, albeit only for part of the health care services. In Belgium, prospective risk-adjusted capitation payment has always been at the heart of the original system in principle since its inception, but non-enforcement led to retrospective and inequitable financing in practice. Although the rhetoric of managed competition has never been used explicitly in any Belgian official government policy document, it seems unlikely that putting the insurers at financial risk without simultaneously also reinforcing their agency role by providing instruments for care management-like, for example, selective contracting--is viable in the longer run without jeopardizing the solvency of the insurers. The authors conclude that although the logic of the managed competition model is appealing, the lack of conclusive empirical evidence of success elsewhere makes governments reluctant to surrender their traditional cost containment tools. But making insurers financially accountable without simultaneously providing them with tools to take on the accountability seems useless and illogical.

Belgium↗
PubMed2002

Language proficiency and the enrollment of Medicaid-eligible children in publicly funded health insurance programs.

OBJECTIVES: The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program. METHODS: 1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted chi2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics. RESULTS: Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to "know-how"--that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes. CONCLUSIONS: This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency.

Aid to Families with Dependent Children↗
PubMed2006

[Expenditures for members of a health insurance company suffering from alcoholism - a payer's view].

AIM: In this study, expenditures of a health insurance company for alcoholics are calculated and analysed. METHOD: Data are derived from the company's records. To participate in this study, subjects had to have a clearly alcohol-related diagnosis during a stay in hospital or a time-off work in 2001 (index-year). 127 Persons were identified according to these criteria. The sample was divided into two groups, those with an alcohol-related diagnosis only in 2001 (Group 1) and those with an alcohol-related diagnosis in at least one other year (Group 2, chronic condition). Expenditures are calculated, cost figures are compared with the health insurance company's average means. For Group 1, the course of costs is examined. Also, cost-predictors are identified. RESULTS: The results show increased costs for alcoholics for all sectors included. Further analyses revealed higher expenditures for persons with a chronic condition (Group 2) and older age. The course of costs for Group 1 shows that expenditures here are clearly increased in the index-year, but not in the other years. CONCLUSIONS: A recurrent diagnosis of alcoholism leads to high costs for health insurance companies. Investments in effective prevention and treatment strategies are recommended to reduce the financial burden.

Adolescent↗
PubMed2000

Hitting a moving target: income-related health insurance subsidies for the uninsured.

New government health insurance programs are likely to emphasize voluntary purchases in a market setting, with subsidies targeted at low-income populations and stress on managed care. Such programs are best structured with a guaranteed enrollment period that is as long as six months to a year. However, given that incomes change over time, errors will be made in awarding income-related subsidies for that long. These errors are assessed in simulations undertaken with longitudinal data from the Survey of Income and Program Participation. Two allocations of the subsidies, based on current income at the beginning of the enrollment period and on actual income assessed at the end, are compared for a variety of program designs. Prospective determination of subsidies is somewhat biased toward overpayment. Net overpayments amount to 5-10 percent of subsidy costs. However, prospective payment encourages participation in the subsidy program. The simulated participation rate for true eligibles is as high as 73 percent with prospective subsidies, compared to 69 percent with retrospective reconciliation. Net overpayments are slightly reduced by testing income less frequently and over longer periods.

Child↗
PubMedDate not supplied

Travel health insurance: indicator of serious travel health risks.

BACKGROUND: Travel health risks documented by questionnaire surveys obtained (e.g., during homebound flights) are incomplete since they miss most patients who need to be repatriated. METHODS: All patient claim files were reviewed from 1997 to 1998, of the largest Swiss travel insurance company. RESULTS: Among 242 claims, 69.4% were due to illness, 30.6% due to accidents; infections were the most frequent illnesses, the extremities were the most frequently traumatized part of the body. Although the illness-to-accident ratio was 1:5 in industrialized countries and the Caribbean, it exceeded 3:0 in some developing regions. Accident proneness was noted in the first week abroad. CONCLUSION: Even if no denominator data are available, this analysis offers an insight in travel health risks, allowing comparison of the occurrences of very different, serious, health problems abroad.

Accidents↗
PubMed2000

Health reform for children: the Egyptian experience with school health insurance.

In June 1992, the People's Assembly of Egypt passed Law 99 expanding health insurance to cover all school children. This was one of the most important initiatives undertaken in recent years by the Ministry of Health, and it effectively increased the number of beneficiaries covered by the Health Insurance Organization (HIO) from 3.75 million in 1988 to about 14 million in 1993. This paper first examines the policy processes for the introduction of this innovation in Egypt's health system. Next, the paper discusses the implementation and consequences of the new policy in terms of coverage, financing, benefits, and delivery of services, along with data on utilization and expenditures. Several important lessons derive from this analysis. First, major reform efforts are possible when there is a strong political commitment and the proposed program and solutions are acceptable to the key stakeholders. Second, compromises and trade-offs are essential to construct a politically feasible and ethically acceptable reform initiative. Third, while these trade-offs might yield short-term gains, the trade-offs in the long term may undermine the reform's capacity to achieve the anticipated equity enhancements and can potentially undermine the financial sustainability of the reform.

Adolescent↗
PubMed2006

Health insurance coverage and cost barriers to needed medical care among U.S. adult cancer survivors age<65 years.

BACKGROUND: The health insurance and cost barriers to care among cancer survivors age <65 years were examined. METHODS: Using the 1998 and 2000 National Health Interview Survey, survivors ages 18 to 64 years (n=1718) were compared with similarly aged adults without cancer (n=50,276) to examine health insurance and reported delayed/missed needed medical care within the previous year because of cost. Findings were initially adjusted for age, sex, race, and ethnicity, and further adjusted for employment, income, health status, marital status, and region. RESULTS: Before adjustment, survivors were less likely to be uninsured (12.4% vs. 18.0%) and more likely to have public insurance (11.2% vs. 6.2%). After initial adjustment, survivors were as likely to lack insurance, less likely to have private insurance, and more likely to have public insurance. After further adjusting, differences in being uninsured were found to be small, differences in having private insurance were eliminated, and differences in having public insurance were reduced. Survivors most likely to lack insurance were younger, female, African-American, or lower income. Survivors, particularly uninsured or publicly insured survivors, were more likely to delay/miss care because of cost. Overall, 20.9% of survivors, including 68% of uninsured survivors, reported delaying/missing needed care. CONCLUSIONS: Health insurance coverage among cancer survivors age<65 years appears to be comparable to that of adults of similar age, sex, race, and ethnicity, but survivors may more likely be publicly insured. Differences are attributable in part to employment, income, and health status, factors potentially influenced by cancer. Unmet medical care needs because of cost were common among survivors, particularly uninsured survivors.

Adult↗