Non-profit medical care insurance in Canada: problems of universal coverage.
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Canada↗
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The demand for private health care under national health insurance: the case of the self-employed.
This study explores the demand for private health care and supplemental health insurance in Israel, where universal national health insurance provides all inhabitants with a standard package of medical care. Our theoretical model and empirical study follow research previously conducted in four other countries. It was found that the self-employed in Israel demand more private health services and supplemental health insurance than wage-earners. Income, age, education, health status, marital status, origin, and profession were found to play a part in explaining these demands.
Employment↗
Current trends in Canadian health care: disease prevention and health promotion.
The Canadian national health insurance plan has not extended to disease prevention in any comprehensive way, and to this extent is incomplete. The Task Force on the Periodic Health Examination has done outstanding work, but no provincial insurance plan has systematically adjusted the benefit schedule to reflect its recommendations. Thus, the place of disease prevention under the Canadian system of universal health insurance is remarkably similar to that in the United States. Health promotion has a somewhat different meaning in Canada from that in the United States, emphasizing intervention at the population level more than health education of individuals. The health promotion movement now enjoys considerable support in Canada, especially in the public health sector, in voluntary agencies, and in the policies of the federal and several provincial departments of health. The movement is almost completely separate from mainstream health services, and is unrelated to the insurance program. To date, there has been mostly talk, but several structures are in place which should lead to action.
Canada↗
Community genetics and dignity in diversity in the Quebec Network of Genetic Medicine.
The Quebec Network of Genetic Medicine (QNGM), implemented in 1971, has been an integrated program of community genetics serving the population (approximately 7.5 million) of Quebec province in Canada. QNGM reported to the Minister of Social Affairs and operated under an umbrella of universal health insurance in the province. The Network's programs have been run by members of the four university medical schools of the province under the direction of a central committee. A global annual budget was awarded to QNGM from its inception. Among its many programs, QNGM supported: (1) two newborn screening programs (using blood and urine samples) for early diagnosis, treatment and research in phenylketonuria, hereditary tyrosinemia, congenital hypothyroidism, and in a large number of other hereditary metabolic diseases; (2) follow-up of confirmatory diagnostic tests at regional centers, followed by supervision of ambulatory treatment modalities; (3) carrier screening and reproductive counseling for Tay-Sachs and beta-thalassemia diseases; (4) a spectrum of feasibility (research) studies (e.g., screening for biotinidase deficiency, neuroblastoma, hemoglobinopathies, and cystic fibrosis) to inform policy decisions. QNGM performed economic analyses of its major programs and followed prevailing ethical guidelines. Its global budget and integrated structure terminated in 1994, although some of its programs continue independently.
Cystic Fibrosis↗
The choice of health insurance plans by university employees.
This study presents the results of a survey of university employees to determine the factors that were important in the choice between two health insurance plans (CHIP vs traditional). The major differences between the plans were their coverage of hospital services, physician office visits, and routine dental services. Separate analyses were conducted for employees of departments associated with the health professions and employees of other departments. The majority of employees selected the CHIP plan, which included coverage of routine dental services. Employees who chose the traditional plan were more likely to have other medical or dental insurance coverage than those who chose CHIP. Multiple regression analyses and discriminant function analyses indicated that the ranking of the importance of coverage of routine dental services and physician office visits were the most important factors in the choice of health insurance plan. These findings indicate that employees may be willing to trade the coverage of other health benefits to secure coverage of routine dental services and physician office visits.
Adult↗
Socioeconomic inequalities in health. No easy solution.
OBJECTIVE: Socioeconomic status (SES) is strongly associated with risk of disease and mortality. Universal health insurance is being debated as one remedy for such health inequalities. This article considers mechanisms through which SES affects health and argues that a broader and more comprehensive approach is needed. DATA SOURCES: Published articles surveyed using MEDLINE and review articles and bibliographies. METHODS AND RESULTS: Research is reviewed on the association of SES with health outcomes in different countries, including those with universal health coverage. Socioeconomic status relates to health at all levels of the SES hierarchy, and access to care accounts for little of this association. Other mechanisms are suggested and implications for policy and clinical practice are discussed. CONCLUSION: Health insurance coverage alone is not likely to reduce significantly SES differences in health. Attention should be paid both in policy decisions and in clinical practice to other SES-related factors that may influence patterns of health and disease.
Female↗
Universal insurance coverage for contraceptives: a public health imperative.
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Contraceptive Agents↗
How expenditure caps and expenditure targets really work.
Every organized payment system must contain its costs in order to keep within revenue without denying benefits. Fixed expenditure caps requiring the provider to operate within its annual financial grant can be imposed on organizations like hospitals, but are fiercely resisted by the medical profession. All financial arrangements with doctors are negotiated, including systems of fixed expenditure caps and more flexible expenditure targets. If the doctors accept the principle of caps and cooperate in achieving them, they do so only as part of a negotiated settlement to avoid a worse outcome. Government's power is minimized, even when government is the payer. Caps on the physicians' sector are unusual. Instead, we see the spread of flexible targeting systems, wherein cost overruns are compensated for by lower expenditure targets the following year. Medical associations in all countries resisted even these restraints for years, but eventually accepted them, provided that target setting, judgments of overruns, utilization control, and all other features are part of a joint negotiating system. Targeting systems are often complicated because they preserve the semiprivate character of statutory health insurance and they are the result of negotiated compromises. To succeed in controlling costs, they require the cooperation of the medical association and of the rank-and-file doctors--but they can succeed. The United States has enacted a small-scale targeting system for Medicare physician payments alone. It cannot become the method for universal health insurance, which must heed lessons from abroad. Only an all-payer system can cover an entire population and contain the costs of the system. A few government officials cannot dictate and implement expenditure goals, but a system of consultation is required for setting and carrying out targets. Impartial officials can regulate hospitals according to the guidelines produced by the consultations, but the record of the medical profession in the countries reviewed here is that they insist on negotiating the final rules and rates. Americans have become bewitched by the mirage of econometric formulas automatically governing a sector, but the real problem is to devise and operate a harmonious decision-making system.
Canada↗
National health insurance reconsidered: dilemmas and opportunities.
Changing social and economic constraints are precipitating a reformulation of the role of government in the provision of social welfare services. The authors conclude that government intervention in the health sector is bound to expand rather than contract because centralization is the key to reconciling otherwise divergent political demands for spending controls and greater equality of access to quality care for the increasing number of uninsured or underinsured persons. In the past eight years, the federal government has unleashed competitive market principles that have had negative side effects on the nation's health services. Payers, providers, and consumers will likely seek to protect themselves by forming coalitions, as happened recently in Massachusetts where the law now requires employers to provide minimum health insurance benefits to their employees. Escalating pressures to correct the damages from short-term piecemeal solutions to problems of health finance and delivery will provide the chief dynamic for universal health insurance in the United States. New economic, social, and political realities suggest, however, an eclectic strategy for attaining this goal that bears little resemblance to the conventional wisdom that guided health policy throughout the postwar period.
Health Expenditures↗
Racial/ethnic disparities in the use of preventive services among the elderly.
OBJECTIVES: Minorities have worse health outcomes compared to whites, which are partially explained by racial/ethnic disparities in use of health services. Less well known, however, are whether these disparities persist among the elderly, the only group that possesses near universal health insurance coverage by Medicare, and how variation in Medicare coverage affects the receipt of preventive services. The scope of racial/ethnic disparities in the use of preventive services in the elderly was assessed, and the impact of the type of health insurance coverage on the use of preventive services was measured. METHODS: Data were derived from the 2001 California Health Interview Survey, a random-digit-dial population-based survey, collected between November 2000 and October 2001. Analysis for this project was conducted in 2004. The association of race/ethnicity and type of health insurance with receipt of preventive services was assessed using bivariate and multivariate logistic regression models. RESULTS: African Americans and Latinos were significantly less likely to be vaccinated for influenza, and Asian Americans were significantly less likely to obtain a mammogram compared to whites, while controlling for other explanatory factors. Moreover, those with Medicare plus Medicaid coverage were significantly less likely to use all four preventive services compared to those with Medicare plus private supplemental insurance. CONCLUSIONS: Despite near-universal coverage by Medicare, racial/ethnic disparities in the use of some preventive services among the elderly persist. Further research should focus on identifying potential cultural and structural barriers to receipt of preventive services aimed at designing effective intervention among high-risk groups.
Aged↗
Profile of uninsured children in the United States.
OBJECTIVES: To describe the demographic characteristics, utilization of medical services, and health status of uninsured children compared with insured children in the United States and to assess the factors associated with lack of health insurance among children. An estimated 8 million children in the United States are uninsured. Medicaid expansions and tax credits have had little impact on the overall problem. An understanding of the characteristics of uninsured children is essential for the design of appropriate outreach and enrollment strategies, benefit packages, and health care provision arrangements for uninsured children. METHODS: Analysis of the 1988 Child Health Supplement of the National Health Interview Survey. RESULTS: Diverse groups of children in the United States lack health insurance. Residence in the South (odds ratio [OR], 2.3) and West (OR, 1.9. [corrected]) and being poor (OR, 2.2) or nearly poor (OR, 2.1) are independently associated with being uninsured. Substantial differences in both sources of care and utilization of medical services exist between uninsured and insured children. Uninsured children lack usual sources of routine care (OR, 3.1) and sick care (OR, 3.8) and also lack appropriate well-child care (OR, 1.5) compared with insured children. Neither being in fair or poor health nor emergency department use are significant independent predictors of being uninsured among children. Children who have a chronic disease, such as asthma, face difficulties of access to care and utilize substantially fewer outpatient and inpatient services. CONCLUSIONS: Universal health insurance, rather than efforts directed at specific groups, appears to be the only way to provide health insurance for all US children. Uninsured and insured children reveal marked discrepancies in access to and utilization of medical services, including preventive services, but have similar rates of chronic health conditions and limitations of activity. Uninsured children do not appear to form a population that will incur higher mean annual expenditures for medical care compared with insured children.
Adolescent↗
Need for health policy in Taiwan: can lessons be learned from the U.S. experience?
In Taiwan, aspiration for a life of high quality is a legitimate objective actively pursued by both the individual and the Government. Since good health is essential to achieve high quality of life, research to facilitate the formulation of health policy is essential to help achieve the objective. Various social and health problems of contemporary society in Taiwan are, to a large extent, our own makings. They are both the causes as well as the consequences of socio-economic development. To undertake policy research in Taiwan, we have the advantages of the experience of the West, more knowledge and technique for policy analysis, and our cultural heritage of stronger familial relationship. We can always learned from the strength as well as the failure of others. Although the policy formulation process in the U.S. has several strength, there are also weaknesses. In spite of the abundance of both resources and technology at her disposal, U.S. has not been able to develop health policies which will assure equity of services to all of her population. The U.S. is not "the healthiest country on earth," and the racial differentials in health status are still substantial. There are large "pockets" of disadvantaged population who do not have any health insurance and therefore, are inaccessble to health care. Six subjects are listed for health policy research of higher priority for Taiwan. These are: 1. Establishment of epidemiologic surveillance system and systems for collection of health information and statistics 2. Setting National Health Objectives for Year 2000 3. The balance between preventive and curative medicine 4. Medical care for the aging population 5. Health and safety of workplaces 6. Medical care cost and universal health insurance program It is the responsibility of academic institutions to help the Government in undertaking these and other policy research to facilitate informed policy decision-making.
Health Policy↗
Holding back the tide: policies to preserve and reconstruct health insurance coverage in Maryland.
Over the past decade, state officials have pursued a variety of strategies to protect and expand health insurance coverage for their residents. This article examines the course of action in Maryland, where new initiatives were shaped around the state's unique hospital payment system and its reimbursement of uncompensated care, an evolving Medicaid and children's health program, and regulation of the small group health insurance market. Several important patterns emerge from the Maryland experience. First, even the most incremental initiatives--programs intended to aid a few thousand beneficiaries--bring into play the very issues that hamper comprehensive reforms: who is deserving of mutual aid and what is the proper role of government versus private entities in administering that aid. In Maryland, these issues generate conflict not only between Democrats and Republicans but also urban and rural interests. Second, all of the important reforms of the past decade were undertaken primarily in reaction to federal policy initiatives. Contrary to rhetoric lauding states as the "laboratories of democracy," the political impetus for reform and basic policy options emerge from interaction between federal and state debates. Third, even with budget surpluses and Democrats in control of the governorship and legislature, Maryland did not move aggressively toward universal health insurance. Now, with a much weaker economy and a new, Republican governor, the primary challenge will be to prevent further erosion of insurance coverage. The Maryland experience reiterates that each step toward greater health security, no matter how small, is a major technical and political challenge and that it will be difficult if not impossible to rely on states to secure coverage for all Americans in the foreseeable future.
Child↗
Inequality and access to health care.
Health services research has laid the groundwork for ongoing policy debates over the shortcomings of the American health care system and the need for the expansion of health insurance protection. In the early 1970s, studies of inequality in access to medical care provided the basis for proposals for national health insurance. The examination of the impact of Medicare and Medicaid demonstrated the critical role of these governmental efforts in reducing inequalities in access to care. By the 1980s the focus of investigation turned to the impact of policies designed to contain the cost of health care on access to medical services by vulnerable populations. Documentation of the negative health outcomes that followed from restrictions on access to care has set the stage for a renewed debate over universal health insurance.
Cost Control↗
Commentary on Canadian health insurance: lessons for the United States.
The Government Accounting Office's comparatively favorable report on Canada's National Health Insurance program (Medicare) prompted a firestorm of reaction: criticism from the health insurance industry primarily and praise from advocates of single-payer models of American reform particularly. Congressional hearings aired this controversy, and this article is a revised version of the author's testimony to the Government Operations Committee, June 18, 1991. The author examines the legitimacy of cross-national comparison as a general analytic tool and the lessons to be learned from North American health care comparisons in particular. In the final section he critically discusses two sets of myths about Canada's experience with universal health insurance: those regarding the desirability of the Canadian system itself and those questioning the transplantability (adaptability) of the model to the United States.
Attitude to Health↗
Cesarean births in Taiwan.
OBJECTIVE: To evaluate the use of cesarean delivery in Taiwan by comparing local clinical indications with those in international cohorts. METHODS: In-patient claims from the National Health Insurance (NHI) in Taiwan were analyzed. Indications for cesarean delivery were evaluated with primary diagnosis codes and procedure codes from the NHI dataset. To produce a stable numerator for cesarean section, 3 years (1998-2000) of claims for cesarean delivery were abstracted and annualized. RESULTS: Rates ranged between 27.3% and 28.7% for primary cesarean delivery and were below 5% for vaginal birth after a cesarean section (VBAC). Compared with rates in other countries, rates for overall and primary cesarean section as well as for VBAC were significantly higher in medical centers in Taiwan (P<0.001). However, the clinics contributed the most to the difference in both overall and primary cesarean rates. The most common indication for cesarean section was prior cesarean section (43.3%-45.5%), followed by malpresentation (19.6%-23.4%). The proportion of fetuses with malpresentation delivered by cesarean section in Taiwan was 7.9%, almost twice the upper limit expected for all pregnancies as indicated in international studies. CONCLUSION: It is important to use appropriately documented data and to compare them with international data when monitoring local obstetric practices. The disproportionately high cesarean delivery rates in Taiwan may hold major lessons for the many countries contemplating or having universal health insurance coverage with a similar mix of providers.
Birthing Centers↗
What can Canada teach us about health care financing?
Canada now spends proportionally more on health care than any other country except the U.S., Sweden and the Netherlands - about 7.2% of its GNP or about $500 per capita. Almost all Canadians (99%) are insured against the cost of all hospital and physician expenses through government health insurance programs administered by the provinces. Hospitals are reimbursed by the government 26 times per year and must work within annual budgets formulated by the Ministry of Health. The fiscal restraints imposed upon hospitals have caused them to look at expansion of shared services, regionalization and a slowed rate of growth. As in the U.S., hospital administrators complain about government regulation on the grounds that individual physicians have a much greater influence over utilization than do hospital administrators. Further hospital cutbacks will have the effect of reducing services and therefore, costs. However, there is concern that these kinds of modifications will result in services among communities which would affect the very principle of universal health insurance for Canadians.
Canada↗
State healthcare reform: an arena for the osteopathic medical profession's influence.
While healthcare reform proposals are debated at the national level, states continue to propose and implement reform measures to address Medicaid, health insurance, universal coverage and access, medical liability, and cost-containment. The authors examine the shared responsibility of the federal and state governments for healthcare regulation and the surprising number of powers that reside with the states. They review the major barriers to state reform represented by restrictions within Medicaid and the Employee Retirement Income Security Act of 1974 (ERISA) legislation. Established state programs in Maryland, Hawaii, and Arizona are revisited, and innovative reforms in Oregon, Tennessee, and Washington are examined. Finally, the authors concentrate on the reform measures under way in the five most heavily DO-populated states, pointing out the potential for one of the big three (Michigan, Pennsylvania, and Ohio) to emerge as a model for the larger states. They urge osteopathic physicians to exert influence, based on their record of serving the Medicaid and other underserved populations, in state settings where they can be most effective.
Health Care Reform↗