U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey

BACKGROUND  Physician opinion can influence the prospects for health care reform, yet there are few recent data on physician views on reform proposals or access to medical care in the United States. OBJECTIVE  To assess physician views on financing options for expanding health care coverage and on access to health care. DESIGN AND PARTICIPANTS  Nationally representative mail survey conducted between March 2007 and October 2007 of U.S. physicians engaged in direct patient care. MEASUREMENTS  Rated support for reform options including financial incentives to induce individuals to purchase health insurance and single-payer national health insurance; rated views of several dimensions of access to care. MAIN RESULTS  1,675 of 3,300 physicians responded (50.8%). Only 9% of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42% preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance. CONCLUSIONS  The vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.     

Single-payer national health insurance. Physicians' views

BACKGROUND: Forty-one million Americans have no health insurance and, despite the growth of managed care, medical costs are again increasing rapidly. One proposed solution is a single-payer health care financing system with universal coverage. Yet, physicians' views of such a system have not been well studied. METHODS: We surveyed a random sample of physicians (from the American Medical Association Masterfile) in Massachusetts, regarding their views on a single-payer health care financing system and other financing and physician work-life issues that such a system might affect. RESULTS: Of 1787 physicians, 904 (50.6%) responded to our survey. When asked which structure would provide the best care for the most people for a fixed amount of money, 63.5% of physicians chose a single-payer system; 10.7%, managed care; and 25.8%, a fee-for-service system. Only 51.9% believed that most physician colleagues would support a single-payer system. Most respondents would give up income to reduce paperwork, agree that it is government's responsibility to ensure the provision of medical care, believe that insurance firms should not play a major role in health care delivery, and would prefer to work under a salary system. CONCLUSIONS: Most physicians in Massachusetts, a state with a high managed care penetration, believe that single-payer financing of health care with universal coverage would provide the best care for the most people, compared with a managed care or fee-for-service system. Physicians' advocacy of single-payer national health insurance could catalyze a renewed push for its adoption.     

Who Are the Uninsured Elderly in the United States?

Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade.     

Universal health care coverage in the United States: is it "slip slidin' away"?

With passage of the Affordable Care Act, affordable health insurance for all Americans is in sight, yet politics could cause it to slip away. A resurgent Republican Party will mount a sustained challenge at the federal and state levels, but the new Congress will not bring about the Affordable Care Act's repeal. More likely, the law's effectiveness could be undermined by congressional restrictions on its implementation, underfunding of programs to improve public health and train more primary care physicians, and resistance by many states to its mandates. Congress could instead seek a bipartisan accord on improving the law, such as by giving the states more options, but this is unlikely in the current polarized environment. This debate is occurring even as the United States faces an unprecedented crisis in access to health insurance coverage, affecting nearly every demographic group, yet the uninsured have largely become an afterthought. Medical professionalism requires a commitment to improving access to care, and physicians could play a crucial role in informing lawmakers that providing all Americans with affordable health care coverage is a moral and medical imperative to prevent needless suffering and death, and must not be allowed to slip away.     

Japanese universal health coverage: evolution, achievements, and challenges

Japan shows the advantages and limitations of pursuing universal health coverage by establishment of employee-based and community-based social health insurance. On the positive side, almost everyone came to be insured in 1961; the enforcement of the same fee schedule for all plans and almost all providers has maintained equity and contained costs; and the co-payment rate has become the same for all, except for elderly people and children. This equity has been achieved by provision of subsidies from general revenues to plans that enrol people with low incomes, and enforcement of cross-subsidisation among the plans to finance the costs of health care for elderly people. On the negative side, the fragmentation of enrolment into 3500 plans has led to a more than a three-times difference in the proportion of income paid as premiums, and the emerging issue of the uninsured population. We advocate consolidation of all plans within prefectures to maintain universal and equitable coverage in view of the ageing society and changes in employment patterns. Countries planning to achieve universal coverage by social health insurance based on employment and residential status should be aware of the limitations of such plans.     

The influence of outpatient insurance coverage on the microvascular complications of non-insulin-dependent diabetes in Mexican Americans

Does poor health insurance coverage contribute to increased microvascular complications (nephropathy and retinopathy) in Mexican Americans with non-insulin-dependent diabetes? Mexican-American subjects with diabetes were identified in a population-based cardiovascular risk factor survey, the San Antonio Heart Study. Retinopathy, nephropathy, source of health care, and type and extent of health insurance coverage were assessed in a special diabetes complications exam. Among Mexican-American subjects with non-insulin-dependent diabetes diagnosed prior to their participation in the survey (n = 255), 26% (n = 67) lacked any type of health insurance, and 28% relied on county- or federal-funded clinics rather than private doctors as their primary source of care. Among those with health insurance (188 of 255), only 68% (127 of 188) or 24% of the total sample had private health insurance, and, of those with private insurance, 48% (35 of 73) received reimbursement for outpatient doctor visits and 57% for outpatient medications. Microvascular complications were more common among those who received their health care from a clinic versus a private doctor, and among those who lacked health insurance coverage for outpatient doctor visits and medications. Thus, poor health insurance coverage in the outpatient setting correlates with higher rates of microvascular complications among Mexican Americans with non-insulin-dependent diabetes mellitus.     

Early appraisal of China's huge and complex health-care reforms

China's 3 year, CN￥850 billion (US$125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The government's undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable. However, transformation of money and insurance coverage into cost-effective services is difficult when delivery of health care is hindered by waste, inefficiencies, poor quality of services, and scarcity and maldistribution of the qualified workforce. China must reform its incentive structures for providers, improve governance of public hospitals, and institute a stronger regulatory system, but these changes have been slowed by opposition from stakeholders and lack of implementation capacity. The pace of reform should be moderated to allow service providers to develop absorptive capacity. Independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable.     

Political and economic aspects of the transition to universal health coverage

Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people. The third is an increase in the share of health spending that is pooled rather than paid out-of-pocket by households. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care--in other cases it is mobilised in the form of contributions to mandatory insurance schemes. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage. This paper describes common patterns in countries that have successfully provided universal access to health care and considers how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health.     

The New Medicaid Under PPACA What Will it Mean for General Internists?

The Patient Protection and Affordable Care Act (ACA) institutionalized Medicaid as a significant and permanent structure in the U.S. health care system. About half of the 32 million Americans expected to gain health insurance coverage under the ACA will be covered under Medicaid. While it is clear general internists will be significantly impacted by Medicaid-related health care reform provisions, its ultimate effect is unclear since these new opportunities also come with some new potential burdens. There are four main areas of impact for general internists to consider: (1) coverage expansions and reimbursement; (2) multiple payers and fragmented coverage; (3) primary care workforce and infrastructure capacity; and (4) delivery model changes.     

Good managed care needs universal health insurance

Although the increase of corporate managed care has helped to reduce excesses and costs, continued gains in cost-effectiveness depend on good clinically managed care. Benefits of clinically managed care depend on stable contracts and universal coverage. Instead, employers are decreasing coverage and creating a market of "lemons" in which low-cost plans are rewarded for cost-cutting tactics. These tactics have spawned movements that demand rights for patients and providers. Choosing to shore up those rights, however, will increase the number of uninsured persons. This tragic choice, which no other industrialized nation has permitted, will not be resolved until some form of universal health insurance is implemented.     

The American Health Care System Is Broken. Part 7: How Can We Fix It?

Previous articles have outlined the many problems that confront America in trying to humanely and efficiently deliver health care to our citizens. First among these is that health care is unaffordable for too many. This final article describes how to expand coverage to all Americans and identifies many specific areas in which changes can be made to both improve care and lower costs. There are many ways to reduce the cost of medications, to improve hospital care while lowering costs, to eliminate “surprise” medical bills, and to cut down fraud and waste. The socioeconomic factors that contribute heavily to our poor health outcomes must be addressed.     

Access to Care and Cardiovascular Disease Prevention: A Cross-Sectional Study in 2 Latino Communities

Cardiovascular disease (CVD) is the leading killer of Americans. CVD is understudied among Latinos, who have high levels of CVD risk factors. This study aimed to determine whether access to health care (ie, insurance status and having a usual source of care) is associated with 4 CVD prevention factors (ie, health care utilization, CVD screening, information received from health care providers, and lifestyle factors) among Latino adults and to evaluate whether the associations depended on CVD clinical risk/disease.Data were collected as part of a community-engaged food environment intervention study in East Los Angeles and Boyle Heights, CA. Logistic regressions were fitted with insurance status and usual source of care as predictors of the 4 CVD prevention factors while controlling for demographics. Analyses were repeated with interactions between self-reported CVD clinical risk/disease and access to care measures.Access to health care significantly increased the odds of CVD prevention. Having a usual source of care was associated with all factors of prevention, whereas being insured was only associated with some factors of prevention. CVD clinical risk/disease did not moderate any associations.Although efforts to reduce CVD risk among Latinos through the Affordable Care Act could be impactful, they might have limited impact in curbing CVD among Latinos, via the law''s expansion of insurance coverage. CVD prevention efforts must expand beyond the provision of insurance to effectively lower CVD rates.     

Evidence-based, cost-effective interventions: how many newborn babies can we save?

In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41-72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality--two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal--ie, for all settings--outreach and family-community care at 90% coverage averts 18-37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high-coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival.     

Reform of how health care is paid for in China: challenges and opportunities

China's current strategy to improve how health services are paid for is headed in the right direction, but much more remains to be done. The problems to be resolved, reflecting the setbacks of recent decades, are substantial: high levels of out-of-pocket payments and cost escalation, stalled progress in providing adequate health insurance for all, widespread inefficiencies in health facilities, uneven quality, extensive inequality, and perverse incentives for hospitals and doctors. China's leadership is taking bold steps to accelerate improvement, including increasing government spending on health and committing to reaching 100% insurance coverage by 2010. China's efforts are part of a worldwide transformation in the financing of health care that will dominate global health in the 21st century. The prospects that China will complete this transformation successfully in the next two decades are good, although success is not guaranteed. The real test, as other countries have experienced, will come when tougher reforms have to be introduced.     

Impact of Broadened Coverage of Smoking Cessation Treatments on Cardiovascular Disease

One third of all premature tobacco-attributable deaths are due to CVD and tobacco is the cause of approximately 15?% of all CVD attributable deaths. Primary and secondary prevention strategies that combine evidenced based tobacco dependence treatment programs along with cigarette taxes and media campaigns can result in hundreds of thousand of fewer excess deaths from smoking attributable CVD. Expanded insurance from both commercial and public insurers will be greatly expanded by the recently enacted federal health care reform but barriers to reducing the avoidable morbidity and mortality that is due to tobacco use is impacted by the potential for remaining financial barriers to full insurance coverage from Americans in regions of the country with the highest smoking prevalence rates.     

Supreme Court review of the Affordable Care Act: the future of health care reform and practice of gastroenterology

After decades of failed attempts to enact comprehensive health care reform, President Obama signed the Patient Protection and Affordable Care Act into law on March 23, 2010. The Affordable Care Act (ACA) has been regarded as the most significant piece of domestic policy legislation since the establishment of Medicare in 1965. The ACA would cover an estimated 32 of the 50 million uninsured Americans by expanding Medicaid, providing subsidies to lower income individuals, establishing health insurance exchanges, and restricting insurance companies from excluding patients from coverage. The ACA also includes many payment and health care delivery system reforms intended to improve quality of care and control health care spending. Soon after passage of the ACA, numerous states and interest groups filed suits challenging its legality. Supreme Court consideration was requested in five cases and the Supreme Court selected one case, brought by 26 states, for review. Oral arguments were heard this spring, March 26-28. The decision will have far reaching consequences for health care in America and the practice of gastroenterology for decades to come. This article reviews the four major issues before the Supreme Court and implications for health care reform and future practice of gastroenterology. Payment reforms, increased accountability, significant pressures for cost control, and new care delivery models will significantly change the future practice of gastroenterology. With these challenges however is a historic opportunity to improve access to care and help realize a more equitable, sustainable, and innovative health care system.     

Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia

We analyse nine low-income and lower-middle-income countries in Africa and Asia that have implemented national health insurance reforms designed to move towards universal health coverage. Using the functions-of-health-systems framework, we describe these countries' approaches to raising prepaid revenues, pooling risk, and purchasing services. Then, using the coverage-box framework, we assess their progress across three dimensions of coverage: who, what services, and what proportion of health costs are covered. We identify some patterns in the structure of these countries' reforms, such as use of tax revenues to subsidise target populations, steps towards broader risk pools, and emphasis on purchasing services through demand-side financing mechanisms. However, none of the reforms purely conform to common health-system archetypes, nor are they identical to each other. We report some trends in these countries' progress towards universal coverage, such as increasing enrolment in government health insurance, a movement towards expanded benefits packages, and decreasing out-of-pocket spending accompanied by increasing government share of spending on health. Common, comparable indicators of progress towards universal coverage are needed to enable countries undergoing reforms to assess outcomes and make midcourse corrections in policy and implementation.     

Health Care Reform and the Primary Care Workforce Bottleneck

To establish and sustain the high-performing health care system envisioned in the Affordable Care Act (ACA), current provisions in the law to strengthen the primary care workforce must be funded, implemented, and tested. However, the United States is heading towards a severe primary care workforce bottleneck due to ballooning demand and vanishing supply. Demand will be fueled by the “silver tsunami” of 80 million Americans retiring over the next 20 years and the expanded insurance coverage for 32 million Americans in the ACA. The primary care workforce is declining because of decreased production and accelerated attrition. To mitigate the looming primary care bottleneck, even bolder policies will be needed to attract, train, and sustain a sufficient number of primary care professionals. General internists must continue their vital leadership in this effort.