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Businesses are in revolt over President Clinton's proposal to require employers to underwrite their workers' health coverage. But it won't be easy to find another way to provide universal coverage without higher taxes.
BACKGROUND: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed. OBJECTIVES: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process. RESEARCH DESIGN: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results. PATIENTS: We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system. MAIN OUTCOMES: Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores. RESULTS: Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05). CONCLUSIONS: Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.
On August 29, 2005, Hurricane Katrina made landfall resulting in catastrophic damage and flooding to New Orleans, LA, and the Gulf Coast, which may have had significant mental health effects on the population. To determine rates and predictors of symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) in New Orleans residents following Hurricane Katrina, we conducted a web-based survey 6 months after Hurricane Katrina made landfall. Participants included 1,542 employees from the largest employer in New Orleans. The prevalence of PTSD symptoms was 19.2%. Predictors of PTSD symptoms in a multivariate-adjusted regression model included female sex, non-black race, knowing someone who died in the storm, not having property insurance, having had a longer evacuation, a much longer work commute compared to before Hurricane Katrina, and currently living in a newly purchased or rented house or in a temporary trailer. Despite universal health coverage and the benefits of an employee assistance program for all employees, only 28.5% of those with PTSD symptoms had talked to a health professional about the events of Hurricane Katrina or issues encountered since the storm. A significant burden of PTSD symptoms was present 6 months following Hurricane Katrina among a large group of adults who had returned to work in New Orleans. Given their key role in the economic redevelopment of the region, there is a tremendous need to identify those in the workforce with symptoms consistent with PTSD and to enhance treatment options. The strong relationship between displacement from one's pre-Katrina residence and symptoms of PTSD suggests a need to focus resource utilization and interventions on individuals living in temporary housing.
Health reform is now predicted to occur in the marketplace without much further governmental intervention. The major vehicles driving this fortuitous trend are the managed care plans, capitated payment, and the development of complex and fiscally awesome health networks organized by hospitals, physicians, and health insurance companies. In the context of this procompetitive environment, potential decreases are projected in current emergency department (ED) volumes, demand for emergency medicine (EM) physicians, and anticipated workload and remuneration of doctors working in EDs. Eventually, mandated universal insurance for 260 million Americans will create a slight increase in total ED visits; additional cost constraints will force the closure of a number of hospital EDs; and EM specialists will experience less ideal working conditions, requiring them to work more hours to maintain their current incomes.
This paper outlines a taxonomy of alternative health care funding avenues and the implications of these alternatives. The current approach to health care funding in Sweden is highlighted and a similar proposal outlined to meet the Hong Kong situation. The benefits of the proposed combination of tax-funded and capped voluntary payments, supplemented by 'moral hazard neutral' fees are presented, in terms of expenditure containment, universal access to health care, and optimal resource allocation.
The HIV epidemic has focused criticism on standard underwriting practices that exclude people with AIDS or at high risk for it from insurance coverage. Insurers have denied the charge that these practices are unfair, claiming instead that whatever is actuarially fair is fair or just. This defense will not work unless we assume that individuals are entitled to gain advantages and deserve losses merely as a result of their health status. That assumption is highly controversial at the level of theory and is inconsistent with many of our moral beliefs and practices, including our insurance practices. We should reject the insurers' argument. Justice in health care requires that we protect equality of opportunity, and that implies sharing the burden of protecting people against health risks. In a just healthcare system, whether mixed or purely public, the insurance scheme is in systematic terms actuarially unfair, for its overall social function must be to guarantee access to appropriate care. This does not mean that in our system insurers are ignoring their obligation to provide access to coverage. The obligation to assure access is primarily a social one, and the failures of access in our system are the result of public failures to meet those obligations. In a just but mixed system, there would be an explicit division of responsibility among public and private insurance schemes. In our mixed but unjust system, both legislators and insurers cynically pretend that the uninsured are the responsibility of the other. The attempt to treat actuarial fairness as a moral notion thus disguises what is really at issue, namely, the risk to insurers of adverse selection and the economic advantages of standard underwriting practices. Standard underwriting practices will be fair only if they are part of a just system, not if they simply are actuarially fair. The failure of the argument from actuarial fairness means that we must face an issue private insurers had hoped to avoid if we are to defend standard underwriting practices at all. In view of the clear risk that a mixed system will fail to assure access to care, the burden falls on defenders of a mixed system. They must show us that its social benefits outweigh its social costs, and that it is possible to have a mixed system that is not only just, but also is superior to a compulsory, universal insurance scheme.
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Great achievements for public health in this century include penicillin, oral contraception, vaccination and transplantation, but the greatest contribution to the health of Norwegians may have been made by social security and the welfare state policies. The beneficial effects of social security include: less social inequality, a factor which in itself makes for better health, some degree of financial security for people who are ill and unable to support themselves or their families, universal availability of medical and health services. This paper explores the ideas and sources from which present-day social security legislation stems. The emergence of state based welfare legislation was inspired by developments in Germany under Bismarck; accident insurance for industrial workers was the first to be introduced in 1894. Several periods of active social security legislation followed at times when labour unions and socialist ideas were strong, supported, to some degree, by radical clergy and public health doctors. Social democratic governments, inspired by the British Beveridge plan towards the end of World War II, took the lead during the long post-war period until the mid 1970s. The Scandinavian model of social security is based on universal coverage and a single payer system. However, since the 1980s, as in other countries of Northern Europe, the social security system has come under pressure from market liberalism. Now at the turn of the century, increasing social inequalities cause some concern for the future of the welfare state.
This presentation provides an alternative explanation of the present composition, nature, and functions of the health sector in the United States to those frequently given in sociological, economic, and medical care literature. These expalantions usually maintain that the Amcerican health sector is a result of the value system of the assumedly middle class American society. In this presentation it is postulated that the present economic structure of the United States determines and maintains a social class structure, both outside and within the health sector, and that the different degrees of ownership, control, and influence that these classes have on the means of production, reproduction, and legitimization in the United States explain the composition, nature, and functions of the health sector. It is further postulated that the value system is not the cuase, but a sysmptom, of these class controls and influences. The paper is divided into three sections. The first part profices a description of the class structure, which includes the corporate class, upper middle class, lower middle class, and working class, and it describes the mechanisms whereby this structure is maintained and replicated, both outside and within the health sector. The second section analyzes: (1)the production characteristics and social make-up of the thre main sectors of the U. S. economy-the monpolistic, state, and competitive sectors-and it focuses especially on the monopolistic sector, which is assumed to be the dominant sector in the U. S. economy, with its needs determining to a large degree the functions of the social sectors, including those of the health sector; (2) the increasing dominance of the monopolistic sector in the health sector, by means of the financial institutions, which conflicts primarily with the providers'relative control of the financing of health services; and (3) the main conflict in the control of the reproductive (academic) an distributive (delivery) institutions which, it is postulated, is not, as is generally belived, between the providers and the so-called consumers, but rather between the corporate and upper middle classes (including the providers), who control those institutions, and the majority of the U. S. population, the lower middle and working classes, who do not control them...
This Issue Brief examines the major issues of the health reform debate. The issues that must be resolved before reform can be enacted include: allocation of health care resources, universal coverage versus universal access, composition of risk pools, employer and individual mandates, and distribution of health care services' costs. This report also contains short descriptions and analyses of the following proposals: McDermott-Wellstone, Clinton administration, Cooper-Breaux, Chafee-Thomas, Michel-Lott, Nickles-Stearns, and Gramm. Proposals without an individual mandate will not achieve universal coverage. An individual mandate raises significant enforcement issues. An employer mandate will not achieve universal coverage by itself. Depending on the number of hours an employee must work to be included in a mandate, an employer mandate could potentially extend health insurance coverage to as many as 85 percent of the currently uninsured. Each individual has a risk of needing health care services. Restructuring the health insurance market is accomplished by changing the way individuals and their risks are pooled. The composition of these risk pools will determine the costs of health insurance and the distribution of these costs. The theory behind medical saving accounts is that the market for health insurance currently leads to health care cost inflation because many events covered under most health insurance plans are not truly insurable. There are two issues involved in medical savings accounts--the impact on low-income individuals and individuals' ability to evaluate the quality of care they receive. The present market does not provide individuals with adequate information for assessing the quality or effectiveness of medical care. Among the critical issues in health reform is how to reduce the rate of health care cost inflation. The effect of proposals that impose explicit budget caps or price controls on health care cost inflation can be more easily estimated than other means of controlling costs if it is assumed that the political will exists to hold these caps and price controls at the levels set in the proposal. It seems unlikely that shortages or queues would develop in the near term if a single-payer health system were enacted. Currently, the U.S. health care system is characterized by overcapacity. In the longer term, however, with restrictions on hospitals' access to new technology and funds to invest in new equipment and beds, shortages and queues might develop.
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This analysis provides new statistics for one of the oldest and fiercest debates in American health policy: whose residents have better access to health care, the United States' or Canada's? Data from the 2002-2003 Joint Canada U.S. Survey of Health show that, despite major differences in their health systems, most Canadians and Americans get the care they need. However, one group of Americans is much more likely to report serious access barriers--the uninsured. About one-third of currently or recently uninsured Americans, aged 18 to 64, said they could not get needed health care (over three times the rate of insured Americans or Canadians). Compared with Canadians and insured Americans, the uninsured are less likely to use hospital or physician services, and those who do are less satisfied with the care they receive. They are also less likely to purchase prescribed medications, due to cost. From a consumer perspective, the most salient feature of the Canadian system is its universality. In contrast, insured Americans under age 65 are at risk of losing their insurance and facing substantial access barriers.
Implementation of social insurance for financing health services has yielded different patterns depending on a country's economic level and its government's political ideology. By the late 19th century, thousands of small sickness funds operated in Europe, and in 1883 Germany's Chancellor Bismarck led the enactment of a law mandating enrollment by low-income workers. Other countries followed, with France completing Western European coverage in 1928. The Russian Revolution in 1917 led to a National Health Service covering everyone from general revenues by 1937. New Zealand legislated universal population coverage in 1939. After World War II, Scandinavian countries extended coverage to everyone and Britain introduced its National Health Service covering everyone with comprehensive care and financed by general revenues in 1948. Outside of Europe Japan adopted health insurance in 1922, covering everyone in 1946. Chile was the first developing country to enact statutory health insurance in 1924 for industrial workers, with extension to all low-income people with its "Servicio Nacional de Salud" in 1952. India covered 3.5 percent of its large population with the Employees' State Insurance Corporation in 1948, and China after its 1949 revolution developed four types of health insurance for designated groups of workers and dependents. Sub-Saharan African countries took limited health insurance actions in the late 1960s and 1970s. By 1980, some 85 countries had enacted social security programs to finance or deliver health services or both.
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Most employees and their dependents in the United States have health insurance provided by the employer or labor-management health and welfare fund. In this system, employees and their families lose their health insurance when the breadwinner loses his or her job while, at the same time, a Medicaid beneficiary can lose Medicaid eligibility by getting a job, even a poorly paid one. Most health insurance pays the doctor on the basis of fee-for-service and the hospital on the basis of cost-reimbursement, rewarding both with more revenue for providing more and more costly services. The insured employee has little or no incentive to seek out a less costly provider. There are no rewards for economy in this system. It should be little wonder, then, that health care costs are out of control. There are alternative financing and delivery systems with built-in incentives to use resources economically, but, the author of this article asserts, their ability to compete and attract patients with their superior economic efficiency is blocked by many laws and government programs. The author believes that the most effective and acceptable way to get costs under control, and at the same time achieve universal coverage, would be through a system of fair economic competition. He discusses his Consumer Choice Health Plan proposal and describes how one of the main barriers to competition is today's system of job-linked health insurance.