International trade regulation and publicly funded health care in Canada.

The World Trade Organization (WTO) creates new challenges for the Canadian health care system, arguably one of the most "socialized" systems in the world today. In particular, the WTO's enhanced trade dispute resolution powers, enforceable with sanctions, may make Canadian health care vulnerable to corporate penetration, particularly in the pharmaceutical and private health services delivery sectors. The Free Trade Agreement and its extension, the North American Free Trade Agreement, gave multinational pharmaceutical companies greater freedom in Canada at the expense of the Canadian generic drug industry. Recent challenges by the WTO have continued this process, which will limit the health care system's ability to control drug costs. And pressure is growing, through WTO's General Agreement on Trade in Services and moves by the Alberta provincial government to privatize health care delivery, to open up the Canadian system to corporate penetration. New WTO agreements will bring increasing pressure to privatize Canada's public health care system and limit government's ability to control pharmaceutical costs.     

Should we abolish the private health insurance industry?

Health care financing can be based on one of two conflicting principles: health care as a right versus the insurance principle. The former assures equal access to care for all people regardless of income, while the latter requires each grouping in society to pay its own way. In the United States, health financing has utilized both principles, with employer-sponsored group health insurance approximating health care as a right. However, the insurance principle is increasingly eroding this right. In five major areas, the private health insurance industry has serious flaws: it has contributed to health care inflation; it wastes billions in administrative and marketing costs; it is unfair to many groups in society; it has undermined the positive features of health maintenance organization reform; and it has far too much political and economic power. In order to establish health care as a right as the guiding principle of U.S. health care financing, the private health insurance industry and the insurance principle should be abolished.     

Myths of competitive reform

During the 1980s, private economists and government policy-makers promoted market competition as a means of controlling costs and improving quality in the health services industry. However, inflation-adjusted costs rose faster during the 1980s than during the 1970s, and most of the expected benefits were not realized. Competitive reform failed because government and private payors were unwilling or unable to force providers to compete primarily on price and quality. Despite its failure to control costs, competitive reform has created a "mythology" that continues to influence health policy to the detriment of effective reform.     

Health care cost containment strategies: the Jordanian experience

Jordan's relative success in containing costs is the result of public financing of the health insurance system, the health care system reform strategy, and expanding the primary care network, which allows for cost containment and universal access based on the need for services rather than the ability to pay. The shift of costs from the public to the private sector must be curtailed. The determinants of health care (i.e. environment; human biology; life style; and health care system) are the main factors that determine future spending on health.     

What happened to long-term care in the health reform debate of 1993-1994? Lessons for the future.

During 1993 and 1994, the United States debated but did not enact major health care reform. Although the reform efforts focused on providing health coverage for the uninsured and controlling acute care costs, many proposals included substantial long-term care initiatives. President Clinton proposed creating a large home-care program for severely disabled people of all ages and all income groups, among several other initiatives. By stressing non-means-tested public programs, the president's plan was a major departure from the Medicaid-dominated financing system for long-term care. In designing the long-term care component, the Clinton administration addressed many of the basic policy choices that must be decided in all reform efforts, including whether initiatives should be limited to older people or cover people of any age, how to balance institutional and noninstitutional care, whether to rely on government programs or on the private sector, and how to control costs. Analyzing the political and intellectual history of long-term care during the health reform debate provides lessons for future reform.     

What Happened to Long‐Term Care in the Health Reform Debate of 1993–1994? Lessons for the Future

During 1993 and 1994, the United States debated but did not enact major health care reform. Although the reform efforts focused on providing health coverage for the uninsured and controlling acute care costs, many proposals included substantial long-term care initiatives. President Clinton proposed creating a large home-care program for severely disabled people of all ages and all income groups, among several other initiatives. By stressing non-means-tested public programs, the president's plan was a major departure from the Medicaid-dominated financing system for long-term care. In designing the long-term care component, the Clinton administration addressed many of the basic policy choices that must be decided in all reform efforts, including whether initiatives should be limited to older people or cover people of any age, how to balance institutional and noninstitutional care, whether to rely on government programs or on the private sector, and how to control costs. Analyzing the political and intellectual history of long-term care during the health reform debate provides lessons for future reform.     

Privatization of the medical market in socialist China: a historical approach

A Socialist-Market Economy was defined as a target model for China's economic reform by China's 14th National Congress in 1992. Such an innovative change in China's more than a decade long economic reform has brought both new challenges and opportunities for its health care system reform as it moves toward a market determination mechanism and involvement of the private sector. A better understanding of the nature and history of the Chinese private medical market and its dynamic socio-economic environment would certainly shed a great deal of light onto the accomplishments of the health care reform. Research in this area, however, is almost non-existent at either national or international levels. The present study attempts to fill this gap by providing a comprehensive assessment of both historical and prospective development of the Chinese private medical market. Three stages are defined to present the tortuous development of this market over the last four decades, coupled with our critiques of the underlying merits and problems. Predictions are also made on the future perspective of the private market, and its possible impact and role in shaping the reform of the entire Chinese health care system. The government's role as well as its future strategy to cope with the issues surrounding Chinese health care reform are also summarized. The study concludes with five health policy recommendations aimed at facilitating China's health care reform via more market-oriented determination of resources allocation, production, and distribution, coupled with promotion of the private sector's involvement while minimizing its potential adverse side effects.     

Chilean health insurance system: a source of inequity and selective social insecurity

More than 20 years after its radical market-oriented reform, the Chilean health care system shows serious equity and fairness problems. Private insurance companies have used ex-ante as well as ex-post risk selection to avoid the affiliation of poorer and older enrolees presenting higher risks. The coexistence of a solidarity-driven public sector and a for-profit private sector operating with risk-adjusted premiums has led to a two-tier health insurance system. Unpredictable, often existentially threatening co-payments have become an serious problem for the users of the Chilean health care system, and coverage-lacks have become a major menace for patients. Private insurers supplement “Cream Skimming” and risk selection with contracts calling for significant out-of-pocket payments for health services. This article develops and applies a methodology to measure and compare systematically the impact of user charges for varying levels and complexity of treatment in the public and private health care sector. Co-payments in the private sub-sector show enormous variation, are hyper-regressive and discriminate not only against the ill, but also against the members of the lower socio-economic classes once they have passed the high access barriers. As cost-sharing affects the financial coverage and thus the accessibility of health care, it has become an important mechanism of quality skimping and active disenrolment. Private health insurance companies are relatively well prepared to cover costs for a wide array of traditional health problems; they fail, however, to respond for the costs of other leading diseases in Chile. The private system seems to be poorly prepared to face the challenges of the epidemiological transition in emerging countries.     

If they get sick, they are in trouble: health care restructuring, user charges, and equity in Vietnam.

The transition from a centrally planned economy in the 1980s and the implementation of a series of neoliberal health policy reform measures in 1989 affected the delivery and financing of Vietnam's health care services. More specifically, legalization of private medical practice, liberalization of the pharmaceutical industry, and introduction of user charges at public health facilities have effectively transformed Vietnam's near universal, publicly funded and provided health services into a highly unregulated private-public mix system, with serious consequences for Vietnam's health system. Using Vietnam's most recent household survey data and published facility-based data, this article examines some of the problems faced by Vietnam's health sector, with particular reference to efficiency, access, and equity. The data reveal four important findings: self-treatment is the dominant mode of treatment for both the poor and nonpoor; there is little or no regulation to protect patients from financial abuse by private medical providers, pharmacies, and drug vendors; in the face of a dwindling share of the state health budget in public hospital revenues and low salaries, hospitals increasingly rely on user charges and insurance premiums to finance services, including generous staff bonuses; and health care costs, especially hospital costs, are substantial for many low- and middle-income households.     

The surprising optimist: why Tom Daschle believes that the country is ready for comprehensive health reform. Interview by Robert Galvin

When Tom Daschle was last a private citizen, Jimmy Carter was president, and the country was embroiled in a debate about how to control health care costs. After a distinguished twenty-six-year career in Congress, Daschle has a lot to say about not only health care costs but overall system reform. With his deep understanding of the inner workings of Congress, Daschle breaks from the prevailing belief that incrementalism is the right approach; comments on the novel use of budget reconciliation to pass reform; and argues that the country, including some business leaders, is ready for comprehensive change with a bigger role for government.     

Are market-oriented health insurance reforms possible in Latin America? The cases of Argentina, Chile and Colombia.

The process of health care reform benefits tremendously from comparing characteristics and performance across nations. This paper studies market-oriented health insurance reforms in three Latin American countries: Argentina, Chile and Colombia. Chile allowed private health insurers to compete for workers payroll contributions in the 1980s, permitting the modernization of the private health sector but relatively impoverishing the public health sector as a consequence of selection practices by private carriers. In the 1990s, Argentina and Colombia started liberalizing the health insurance sector but using policies to avoid the adverse effects encountered in the Chilean experience. These policies are scrutinized while challenges for these and future health insurance reform processes are discussed.     

中国社会办医的现状分析

通过系统分析中国社会办医的现状,为进一步促进社会办医提出政策建议。根据国内外文献,社会办医疗机构和公立医疗机构在医疗费用和服务质量方面并没有显著差异,并且由于社会办医促进市场开放与公平竞争,公立医院和整个医疗卫生服务市场的绩效也因此有所提高（正向溢出效应）。尽管如此,由于中国长期计划经济自上而下的资源配置与行政干预,社会办医长期未能得到健康发展,主要政策障碍包括准入方面存在隐形限制、经营方面缺乏税收鼓励、用人方面缺少优质医师资源。因此,建议调整区域卫生规划的功能从“封顸”向“兜底”过渡,尽快制定有利于社会办医的土地政策和人才政策,进一步完善相关配套措施,促进社会办医在中国的健康发展。     

Turning swords into plowshares: lessons from the military health system

Policymakers are searching everywhere for examples of how best to reform the nation's health care system. A major reform model from an unexpected quarter--the U.S. military--is making great strides forward and contains many of the ingredients in the national reform debate: global budgeting, pooled-payer funding, private industry competition, managed care, prevention, and reallocation of resources.     

President Bush's comprehensive health reform program

To deal with the shortcomings of the current U.S. health care system, President Bush has proposed a comprehensive reform package that would offer tax credits and deductions to low- and middle-income Americans to purchase private insurance, reform small market insurance to ensure availability and portability of insurance, allow creation of Health Insurance Networks to allow small businesses and nonprofit organizations to pool their purchasing power, reduce administrative costs, and control the growth of government health programs. Combined, the proposals would build on the strengths of the present private/public system and preserve consumer choice and free market discipline.     

Antitrust implications of health care reform

Antitrust issues affect the insurance industry, hospital industry, and physicians. The authors explore the history of antitrust issues in the health care field and implications for future developments. Interest in antitrust has increased due to current merger and acquisition activities in the industry. With the failure of the Health Security Act, health care reform will be left to private industry. Will there be increasing or decreasing antitrust activity by the Department of Justice and Federal Trade Commission?     

Re‐examining the effects of public health insurance: The case of nonpoor children in Vietnam

This paper focuses on the effects of a 2005 health insurance reform in Vietnam. Through this reform, public health insurance was newly offered to nonpoor children under 6 years old, but it required the use of community health facilities. This requirement potentially limited the value of the insurance. Employing difference‐in‐discontinuities and triple‐difference methods and using data from 2002, 2004, and 2006, I show that, despite health coverage among nonpoor children increasing by nearly three times, there is little or no evidence that the reform significantly increased health care utilization, changed care locations from private to public sites, lowered out‐of‐pocket costs, or improved health status for nonpoor young children. My results suggest a “bypassing” phenomenon whereby nonpoor families skipped free health care at low‐quality facilities.     

Implications of managed care in a publicly funded health care delivery system.

In the light of federal cuts in the Medicaid budget, the Medicaid-funded health delivery system is under severe cost pressures, especially in publicly funded institutions. In the private health insurance industry, managed care innovations have successfully restrained costs. For publicly funded institutions to remain viable, managed care contracts must be implemented for the Medicaid system as well. Managed care holds promise for reducing costs as well as reducing many of the current barriers to quality health care for the indigent.     

Privatizing public mental health and substance abuse services: issues, opportunities, and challenges

Much like the medical care system, delivery systems for mental health and substance abuse services are being transformed rapidly by managed care. Public sector systems are now facing challenges to transfer service delivery responsibilities to private managed behavioral health care organizations as a way of containing treatment costs and realizing operational efficiencies. These privatization efforts entail a range of quality management issues that are specific to mental health and substance abuse problems, treatments, and clients.     

Forces for reforming the U.S. health care system: a review of the cost and access issues.

In recent years, a spate of health care reform proposals have emerged on the American agenda. Although the elements of the reform proposals often vary substantially, most of the initiatives are fuelled by two common concerns: rising health care expenditures and a growing uninsured population. National health spending, for example, commands an increasing share of U.S. gross national product despite numerous cost-containment efforts initiated by public and private payers throughout the 1980s. And the uninsured population continues to grow--by an estimated 30 percent between 1978 and 1989. To facilitate understanding of the public policy options being considered to address these concerns, the article examines U.S. health care expenditure data and some of the causes of rising health care costs. The article also discusses the demographic characteristics of the uninsured population, the reasons why they lack health coverage, and the health consequences associated with being uninsured.