Patients' rights after health care reform: who decides what is medically necessary?

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers.     

Modelling the affordability and distributional implications of future health care financing options in South Africa

South Africa is considering introducing a universal health care system. A key concern for policy-makers and the general public is whether or not this reform is affordable. Modelling the resource and revenue generation requirements of alternative reform options is critical to inform decision-making. This paper considers three reform scenarios: universal coverage funded by increased allocations to health from general tax and additional dedicated taxes; an alternative reform option of extending private health insurance coverage to all formal sector workers and their dependents with the remainder using tax-funded services; and maintaining the status quo. Each scenario was modelled over a 15-year period using a spreadsheet model. Statistical analyses were also undertaken to evaluate the impact of options on the distribution of health care financing burden and benefits from using health services across socio-economic groups. Universal coverage would result in total health care spending levels equivalent to 8.6% of gross domestic product (GDP), which is comparable to current spending levels. It is lower than the status quo option (9.5% of GDP) and far lower than the option of expanding private insurance cover (over 13% of GDP). However, public funding of health services would have to increase substantially. Despite this, universal coverage would result in the most progressive financing system if the additional public funding requirements are generated through a surcharge on taxable income (but not if VAT is increased). The extended private insurance scheme option would be the least progressive and would impose a very high payment burden; total health care payments on average would be 10.7% of household consumption expenditure compared with the universal coverage (6.7%) and status quo (7.5%) options. The least pro-rich distribution of service benefits would be achieved under universal coverage. Universal coverage is affordable and would promote health system equity, but needs careful design to ensure its long-term sustainability.     

The potential impact of health care reform on public health HIV-related activities.

This article observes that, despite the clear potential benefits of health care reform's expanding health insurance coverage for people with human immunodeficiency virus (HIV) disease, there is a real danger of losing existing acquired immunodeficiency syndrome (AIDS) services if federal categorical public health programs are cut. It discusses the considerable accomplishments of the Ryan White CARE Act and of Centers for Disease Control and Prevention (CDC) prevention funding. The funding for these current efforts will not be assumed by near universal insurance coverage for a variety of reasons, including the need to care for populations who are neglected by health care reform, to continue services unlikely to be reimbursable, and to offer care in a range of locations other than licensed health care facilities.     

The Canadian health care system: an overview

Although health care is a provincial responsibility in Canada, universal hospital insurance was fully adopted by 1961; universal medical insurance followed 10 years later. Each province enacted universal insurance after the federal government offered to pay 50% of provincial hospital and medical care costs. Hospital insurance had wide public and provider support but universal medical care insurance was opposed by organized medicine. The federal government soon realized that it had no control over total expenditures and no mechanisms for controlling costs. In 1977 it enacted Bill C-37 which limited total federal contributions and made those contributions independent of provincial health care expenditures so that increased costs had to be met by the provinces. Since private health care insurance for universal benefits is prohibited by the federal terms of reference for health insurance, the provinces must raise the money by taxes and (in some provinces) premiums. Although prohibited by the terms of reference of the universal program, some provinces have adopted hospital user fees and are allowing their physicians to bill patients in excess of provincial fee schedules. The 1980s have seen increased confrontations between the federal and provincial governments and between the provinces and their providers. The issues are cost containment and control of the system. The provinces have two broad options. The first is more private funding through private insurance and user fees. The proposed new Canada Health Act will probably prohibit such charges. A second option involves greater control and management of the system by the provinces; this has already occurred in Quebec. Greater control is vigorously opposed by physicians and hospitals. The Canadian solution to health insurance problems in the past has been moderation. Extreme moves in either direction would represent a break with tradition, but they may prove to be unavoidable.     

An equitable way to pay for universal coverage.

This article describes a way to finance universal health care coverage that preserves much of the current financing system and replaces funds obtained from regressive sources with revenue from more progressive ones. New funding would be needed for 24 percent of health expenditures and would be raised through an increase in the federal personal income tax. Premiums are eliminated since their cost is the same to everyone regardless of income. Cost sharing and out-of-pocket spending for medically necessary services are also abolished. In a more equitably financed system, employers would pay a new payroll tax that raised the same amount of money they currently spend for employee health insurance premiums; this would require a payroll tax of about 7 percent. Revenue from an increase in federal personal income taxes would replace household out-of-pocket expenditures for medically necessary services and payments for insurance premiums. For the average, middle-income family, the tax increase would total $731 in 1998. In exchange for the tax increase, no American or American employer would need to buy health insurance or face out-of-pocket charges for any medically indicated health care.     

Working on reform. How workers' compensation medical care is affected by health care reform.

The medical component of workers'' compensation programs-now costing over $24 billion annually-and the rest of the nation''s medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers'' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers'' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers'' compensation and traditional health insurance. What is the relationship of the workers'' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?     

Toward a health care financing strategy for the nation. Report of the National Health Policy Seminar.

All people in the United States have a need for access to comprehensive high quality health care. Such need is so universal and fundamental, not only to personal health, but also to equitable pursuit of all opportunity in a modern and just society, that it is viewed increasingly in the context of rights. Although the current array of health financing programs--Medicare, Medicaid, employer-based medical care insurance benefits, private medical care insurance, and other current insurance methods--have major accomplishments to their credit in providing access to care, the United States falls short in guaranteeing that conceptual right. The result is that 35 to 40 million people in the United States have no insurance coverage at all for medical care expenses, and an unknown number of people have coverage that is grossly inadequate. In addition, our current medical care system is characterized by: significant barriers to equitable access to care, apart from lack of coverage of the direct costs; major deficiencies in services for rehabilitation, long-term care, and home care; extreme variablity in the utilization and quality of care. We also must acknowledge failures in fundamental programs that directly affect the health of our people, such as health manpower, housing, education, and protection against occupational and environmental hazards. However, these matters are outside the purview of this statement. We propose a program, under the leadership of the federal government, with state and local government and the private sector having significant roles to play, that will respond to these shortcomings in our health care system. The program would finance health services comprehensively and equitably, minimize duplication, inefficiency, and the uneven quality of care, and would emphasize health promotion and disease prevention.     

An American macromanaged health care system?

The implementation of President Clinton's proposed health reform plan that ensures universal access and relatively comprehensive health insurance benefits to over 250 million Americans would have a significant impact on their hospitals, physicians, and other health care providers. With this projected coverage, the 36.7 million Americans now uninsured would demand an additional volume of services. It is doubtful, because of this nation's trade and budget deficits, that any significant increases in expenditures for health will be made available from the public sector. Therefore, providers in the US will need to deliver significantly more care with a minimal increase in total reimbursement. These conclusions are further supported by the experiences of the Canadian and the German macromanaged health care systems that provide considerably more hospital and physician services per person per year than the US at a lesser cost per discharge and percentage of their respective nation's gross domestic product. America may be heading toward macromanaged global budget targets, but for political and other reasons President Clinton's health reform plan will be implemented with a multi-payer, managed competition approach.     

A review of the 'welfare state' and alternative ways of delivering health care.

There was no such thing as a public policy for quality health care in the inception of what we now address as the 'welfare state'. The main objectives of those supporting the idea, epitomized by the 'freedom from want' that Beveridge postulated in his now famous November 1942 Report on Social Insurance and Allied Services, was to extend the benefits of social insurance, that is access to services such as health care, to every individual. In the same fashion, post World War II initiatives in Latin America somewhat disregarded the intrinsic quality of health care services, provided they were distributed equally, at least among the urban people. Therefore, it is licit to ascertain that the main, albeit implicit, quality feature of health care was access, that is the ability to reach the entire population with the available services. The health care reform movement following the welfare state crisis, from the Jackson Hole group and Einthoven's managed competition in the United States to the internal markets proposals in different European countries, started when universal coverage had been achieved where it had been pursued, and disregarded elsewhere. In other words, access as a measure of health care quality was not the point. Instead, the subject of both academic research and administrative initiatives was the quality of the health services effectively provided to the population. Furthermore, the World Health Organization in its World Health Report 2000 explicitly excluded access as an item to be assessed in the process of evaluating health systems, although many countries had not achieved, nor were even near, universal coverage. Therefore, notwithstanding the relevance of the continuous quality improvement of the health services actually delivered to the people, access should always be the first quality concern to those health systems lacking universal coverage of the population they are supposed to serve.     

What can the Canadians and Americans learn from each other's health care systems?

Numerous papers have been written comparing the Canadian and US healthcare systems, and a number of health policy experts have recommended that the Americans implement their single‐payer system to save 12–20% of its healthcare expenditures. This paper is different in that it assumes that neither country will undertake a significant philosophic or structural change in their healthcare system, but there are lessons to be learned that are inherent in one that could be a major breakthrough for the other. Following the model in Canada and in Western Europe, the USA could implement universal health insurance so that the 32.0 million (2015) Americans still uninsured would have at least minimal coverage when incurring medical expenditures. Also, the USA could use smart cards to evaluate eligibility and to process health insurance claims; these changes resulting in an estimated 15% reduction in US health expenditures without adversely effecting access or quality of care. Such a strategy would result in the eventual loss of 2.5 million white‐collar jobs at hospitals, physician offices and insurance companies, a long‐term economic gain. Only a few would agree with the statement that Canada already functions with a multi‐payer reimbursement system as evidenced by (1) a federal‐provincial, tax‐supported plan, administered by each of the provinces, providing universal coverage for hospital and physician services and (2) roughly 60% of its residents receiving employer‐paid health insurance benefits, underwritten primarily by investor‐owned plans, that are less than effective to reimburse for pharmaceuticals, dental and other healthcare services. What could be learned from the USA and particularly from Western European countries is possibly implementing an approach, whereby at least upper‐income Canadians could opt out of their federal‐provincial plan and purchase private insurance coverage — being eligible for far more comprehensive “private” benefits for hospital, physician, pharmaceutical, dental and other healthcare services. Aside from generating billions of additional needed revenues from the private sector, it could (1) help eliminate long waits for non‐emergent physicians' care by appointing newly minted specialists to their medical staffs; (2) offer prompt admissions for elective cases to “private” wings of hospitals; (3) increase available funding for what is currently an undercapitalized system; (4) enhance the system's sluggish operations; and (5) encourage more competition among various providers. Although such a two‐tier approach, such as available in the USA and elsewhere, is politically dead on arrival in Canada today, private insurance being already legal and commonly available there. Interestingly, this recommended solution is utilized in most western European countries where there is a higher percentage than in Canada of public (versus private) funding of their total health expenditures. Because of various vested interests, attempts to implement any of the aforementioned proposals will undoubtedly result in considerable political rancor. There is greater likelihood, however, that the Canadians because their need to be more effective and efficient in their delivery of care, and their overall long‐term fiscal outlook will agree to the further privatization of their healthcare system before the Americans will mandate universal access, use the smart card to process insurance eligibility and claims or will impose price controls on high‐tech services and on pharmaceuticals. Copyright © 2016 John Wiley & Sons, Ltd.     

Health care reform and family planning services

With the reforms expected for US health care, the question remains as to the impact on family planning services. Although the focus is on health care finance reform, the mix of patients seen, the incentives for decision making, and the interactions between health care providers will change. Definition of key concepts is provided for universal access, managed competition, and managed care. The position of the obstetrician/gynecologist (Ob/Gyn) does not fit well within the scheme for managed health care, because Ob/Gyns are both primary care providers and specialists in women's health care. Most managed health care systems presently consider Ob/Gyn to be a specialty. Public family planning clinics, which have a client constituency of primarily uninsured women, may have to compete with traditional private sector providers. "Ambulatory health care providers" have developed a reputation for high quality, cost effective preventive health care services; this record should place providers with a range of services in a successful position. Family planning providers in a managed competition system will be at a disadvantage. 3 scenarios possible under managed competition are identified as the best case, out of the mainstream, and most likely. The best case is when primary reproductive health care services, contraception, sexually transmitted disease screening and management, and preventive services are all obtained directly from reproductive health care providers. Under managed care, this means allowing for an additional entry gatekeeper to specialized services. The benefits are to clients who prefer seeing reproductive health care providers first; reproductive services would be separated from medical services. The out of the mainstream scenario would place contraceptive services and other preventive services as outside the mandated benefits. The government would still provide Title X type programs for the indigent. The most likely scenario is one where primary care providers offer contraceptive services, and some family planning providers would expand their services to include nonreproductive health care. Abortion services are presently out of the health care mainstream, and efforts will need to be made to identify impact on reproductive and family planning practices and to advocate for specific provisions in health care reform.     

Prudence in international comparisons: insights for the United States from the Canadian health insurance experience.

Canadian social insurance for medical care started in the province of Saskatchewan in 1946, when conditions were very different from those in the United States today. The Cooperative Commonwealth Federation political party has no counterpart in the United States today. Voluntary insurance was weak in the Canadian priaries, but currently strong in the United States. The U.S. Medicare and Medicaid programs help elderly and poor people, but Saskatchewan lacked such programs. Separation of executive and legislative powers in the United States differs from unified powers in Canada. However, there are several similarities between the U.S. federation of states, and the Canadian provinces. The U.S. Democratic Party has a progressive wing. Voluntary insurance in the United States grew weaker in the 1980s. The U.S. health care crisis on costs today is equivalent to post-Depression conditions in Canada. Both countries are dominated by private fee-for-service medical care, but access to that care has been promoted by compulsory insurance laws in several U.S. states. Therefore, the United States could well emulate Canada by action of the states, which would lead eventually to federal action. Coverage should be universal, with limited benefits initially; gradually, benefits would be broadened.     

Incentives for voluntary health insurance in a national health system: Evidence from Italy

ObjectivesThe paper evaluates the extent to which the government's policy to encourage the purchase of voluntary health insurance (VHI) may have led to income-related horizontal inequity in access to health care in a universal health care system (NHS).MethodsAd hoc tax return data for the universe of Italian taxpayers for years 2009-2016 are used to estimate the tax benefits granted to taxpayers who hold VHI, the redistributive impact, and the public budget effect. The income elasticity of tax benefits is estimated using tax return data and considering some taxpayers’ characteristics (income class, gender, age, and geographic area). Standard inequality indices are computed to assess income-related horizontal inequity in access to health care.ResultsTax incentives, especially those granted to employer-paid health insurance, have a sizeable impact on tax revenue and introduce into the Italian NHS significant income-related horizontal and vertical inequity in access to health care. The results suggest a distributional profile of tax incentives that is highly concentrated in favor of wealthier taxpayers.ConclusionOur analysis adds novel evidence that may contribute to the current debate on whether and to what extent countries in which all citizens have access to free healthcare and equal standards of healthcare services should subsidize VHI, especially when the coverage doubles the healthcare services provided by universal public insurance. We show that VHI reduces tax revenues and introduces disparities among citizens in terms of access to healthcare services.     

The determinants of long-term care utilization and equity of access to care among older adults in Dong-Ku of Incheon Metropolitan city, South Korea

Under the current health care system, around three percent of the elderly remain uninsured. Based on the 2003 Dong-Ku Health Status Survey and the Aday and Andersen Access Framework, the present study examined the social and behavioral determinants of long-term care utilization and the extent to which equity in the use of long-term care services for the elderly has been achieved. The results indicate that universal health insurance system has not yielded a fully equitable distribution of services. Type of coverage and resource availability do not remain predictors of long-term care utilization. The data suggest that a universal health insurance system exists in South Korea with significant access problems for the population without insurance. Access differences also arise from obstacles in expanding the scope and level of plan benefits due to financial disparity among insurers. Health policy reforms must continue to concentrate on extending insurance coverage to the uninsured and establishing long-term insurance system for the elderly.     

Massachusetts's experience suggests coverage alone is insufficient to increase addiction disorders treatment

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.     

Universal health insurance: lessons of the 1970s, prospects for the 1990s

In the 1970s, proposals for universal health insurance were not successful. Health care providers, insurers, and others negotiating in the political process foresaw a better future without such legislation. Today, the growth of health insurance coverage has unmistakably reversed. Moral discomfort and self-interest shape the new politics of universal health insurance for the 1990s. Hospitals, physicians, insurers, employers, and tens of millions of individuals would benefit from a universal health insurance plan that was mindful of their concerns and interests. Proposals that require employers to provide insurance for full-time employees and expand public programs to cover to cover other uninsured persons now have the greatest chances for enactment. As leaders, health services and health insurance executives should be in the vanguard of efforts to enact universal health insurance.     

Rates of Insurance for Injured Patients Before and After Health Care Reform in Massachusetts: A Possible Case of Double Jeopardy

Objectives. We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform.Methods. We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004–2005) and after (2009–2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes.Results. Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% (P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients.Conclusions. Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in “double jeopardy” of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate.The burden of uncompensated care on the health care system and risk of personal financial ruin of uninsured individuals who experience a health shock (unexpected serious illness or accident)1 are among the leading arguments in favor of an individual mandate in the 2010 federal health care reform legislation. Modeled after the Massachusetts health care reform implemented in 2006,2,3 comprehensive federal health care reform is presumed to result in the greatest gains of health insurance among able-bodied adults aged 18 to 64 years mandated to enroll in subsidized or unsubsidized insurance plans. Although opponents of an individual mandate may argue that otherwise healthy adults with minimal health care needs should not be required to purchase health insurance,4 no individual, irrespective of age or baseline health status, is immune to risk of injury. Trauma represents a significant health shock experienced by able-bodied, community-dwelling adults aged 18 to 64 years and is a leading cause of death and disability in this demographic group.5,6Another federal mandate enacted by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency care to individuals experiencing a health shock, regardless of whether they are insured.7 Not surprisingly, emergency department (ED) resource use in response to health shocks has been shown to be independent of insurance status.8 In Massachusetts, implementation of health care reform did not affect trends in ED use.9 Patient care in the face of a health shock, however, rarely stops in the ED.When injured patients without insurance arrive at a trauma center, they are not only stabilized, as mandated by EMTALA, but also provided comprehensive trauma care as required of verified trauma centers in our proven national and state-level trauma systems.10,11 Even after stabilization, injured patients often cannot be released because they are critically ill or require treatments (e.g., intravenous antibiotics, chest tube monitoring) that for practical reasons or out-of-pocket costs cannot be rendered outside of the hospital. These uninsured patients are often provided ongoing free care at the presenting hospital or transferred once stabilized to safety-net hospitals that typically do not refuse patients on the basis of insurance.12 Depending on governance structure (publicly managed, publicly funded, or private nonprofit), 5% to 16% of patients at safety-net hospitals are provided free care.13 Data from the 2004 Medical Expenditure Panel Survey suggested that only 35% (95% confidence interval [CI] = 26%, 45%) of charges to uninsured patients for non–life-threatening emergency services were recouped by hospitals.14 In the case of injuries too severe to be treated and released, the burden of the cost of care is therefore assumed one way or another by the health care system, raising costs for everyone. Furthermore, uninsured patients often incur greater costs of care compared with their insured counterparts, as they must remain hospitalized until they can be safely discharged home because no similar laws mandate uncompensated home health services, skilled nursing, or rehabilitation often required by medically stable injured patients.15–17Proponents of an individual mandate might presume that improved rates of insurance in the general population would result in fewer uninsured injured patients treated at trauma centers, but the effect of an individual mandate on insurance coverage among injured patients is unknown. Therefore, the effects of health care reform on the burden of uncompensated trauma care in Massachusetts may have important national implications on the potential effect of national health care reform on our nation’s trauma system. We undertook this study to determine how an individual mandate affected insurance status among injured Massachusetts residents. We hypothesized that we would have treated fewer uninsured patients after implementation of Massachusetts health care reform. Presumably, the individual mandate would have resulted in rates of insurance among our patients as observed statewide.     

Universal health insurance in Canada

This paper describes the universal health insurance program in Canada and identifies the historical events and social values leading to its adoption. Universal hospital insurance was adopted in 1958, ten years before medical insurance, as a result hospital-based patterns of practice were solidified. Through cost sharing, the federal government influenced the provinces to enact relatively uniform universal plans. From 1951 to 1971 health care expenditures rose rapidly to 7.3% of the gross national product (GNP), but have since decreased and stabilized at about 6.9%. In contrast, health care in the United States represents 8.6% of GNP. Hospital use also increased rapidly in Canada to 1970 but appears to have stabilized and decreased slightly in this decade. Physician incomes rose rapidly before 1971, but since then the increases have slowed and relative incomes of physicians have fallen. Althouth the percent of GNP spent for health care has leveled, there are still substantial annual increases in expenditures that are paid for by government. Two federal initiatives, Bill C-37 and the Lalonde Report, have their roots in cost containment; Bill C-37 transfers greater taxing authority from the federal government to the provinces. To meet the goal of containing costs, provincial governments are moving in the direction of regionalization, decentralization, and greater coordination. In the short term, the provinces have limited hospital budgetary increases to percentages less than the rate of inflation. Cost constraints may be long overdue. Imposing fiscal limits encourages rational planning. It does not appear that the health of Canadians will be adversely affected or essential benefits curtailed by present budgetary restrictions or reorganization.     

Health for all in the Republic of Korea: one country's experience with implementing universal health care

Health care reforms in many countries face the twin challenges of providing universal coverage while controlling spiraling costs. Sixteen years ago the Republic of Korea had no national plan for health insurance, and only 8.8% of the population was covered. In 1975, health care accounted for 2.8% of GDP with government providing 12% of the finances. In 1977, Korea adopted a policy designed to achieve universal coverage while maintaining fee-for-service reimbursement. Korea incrementally established an employer based health care scheme by first mandating coverage for businesses, then government employees and teachers. Coverage was later extended to the poor, the self-employed, and residents of rural areas. Independent insurance societies manage each scheme, set premiums and co-payments, and are responsible for maintaining financial viability. By 1991, 30% of Korea's health care expenditures were from public funds, and health care costs had risen to 7.1% of GDP. Health care reform in Korea has been successful in achieving universal coverage, providing for a full range of services, and eliminating adverse selection. The system is financially solvent, costs are equitably distributed with the government providing subsidies when necessary, and small businesses have not been unduly burdened economically. Attempts to limit costs, however, have been unsuccessful. Patient demand for health care has remained surprisingly resistant to increasing co-payments. Providers have responded to lower physician and hospital fees by providing shorter, more frequent patient visits, relabeling services, and increasing hospital admissions. Competition between insurance societies has not materialized in a meaningful way to control costs.     

How do we heal the Argentine health care system?]

This article proposes a set of measures to reform the Argentine health care system and turn the country's current crisis into an opportunity for progressive, sustainable change. The proposal consists of a model for the intergovernmental division of health responsibilities. The national government would be responsible for strengthening its leadership role and for developing national insurance for low-prevalence high-cost diseases. With the provincial governments, the insurance role would be strengthened, with public health insurance making certain that there is universal coverage. Public hospitals would function as autonomous entities financed by social insurance, private insurance, and provincial public insurance. Municipalities would have an active role in disease prevention and health promotion, principally through primary care.