The arguments against a national health program: science or ideology?

This article provides empirical information that questions some of the major arguments put forward against the establishment of a comprehensive and universal health program in the United State. The positions that (1) "Americans do not want a further expansion of government roles in their lives," (2) "a National Health Program would further increase the rate of growth of health expenditures," (3) "the federal deficit is too large and needs to be reduced before establishing a National Health Program," and (4) "people do not want to pay higher taxes," are shown to be ideological rather than scientific. The author presents evidence that questions each of these assumptions.     

A universal access plan: a step toward national health insurance?

There is increasing interest by the public and by many providers in the enactment of a universal access plan for the more than 60 million Americans who are now without health insurance benefits at some time during each year. After discussing the heterogeneous characteristics of those such a plan would cover, the reasons that some key players are now supporters of a minimal benefit plan, and the funding options for such a proposal, it is concluded that there is growing support for a universal access plan to be enacted soon. The almost insurmountable issues of such a plan involve the determination of eligibility and the specific benefits to be provided, the cost and administration of the new coverage, and the predictable increase in the nation's expenditure for health care services. This article concludes with the opinion that the passage of a universal access plan is a necessary and incremental step that will provide additional time for the discussion of whether and, if so, when the United States will be prepared to implement the final steps toward a more single-payer, centrally controlled health care delivery system.     

Voluntary or compulsory health care reform? The case of primary care organisations in Scotland

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.     

Can insurance increase financial risk? The curious case of health insurance in China

We analyze the effect of insurance on the probability of an individual incurring ‘high’ annual health expenses using data from three household surveys. All come from China, a country where providers are paid fee-for-service according to a schedule that encourages the overprovision of high-tech care and who are only lightly regulated. We define annual spending as ‘high’ if it exceeds a threshold of local average income and as ‘catastrophic’ if it exceeds a threshold of the household's own per capita income. Our estimates allow for different thresholds and for the possible endogeneity of health insurance (we use instrumental variables and fixed effects). Our main results suggest that in all three surveys health insurance increases the risk of high and catastrophic spending. Further analysis suggests that this is due to insurance encouraging people to seek care when sick and to seek care from higher-level providers.     

Price: a market signal of quality in health care insurance policies?

Choosing a good quality health insurance policy is important for most individuals in this country. The choice task is however, made quite complicated by the existence of many alternative policies which are each characterized by multiple attributes. This paper examines whether the price (i.e., premium) of a health insurance plan can give a reliable signal about the objective quality level of the plan. Empirical analysis of real-world data shows that overall, price is positively correlated with such quality. Statistical significance tests are conducted to separately evaluate such correlations for different categories of health insurances. Finally, the empirical results are used to indicate implications for consumer decision making.     

Achieving universal health insurance in Korea: a model for other developing countries?

As developing countries explore alternative methods to provide universal health insurance coverage, one potential model is South Korea. In twelve years (from 1977 to 1989), Korea was able to achieve universal health insurance coverage first by mandating employer based health insurance coverage for medium and large firms and then by establishing regional health insurance systems for small firms, farmers and the self-employed. A government medical aid insurance program was instituted for low income citizens. The specifics of the plan and some of the issues encountered in implementing the plan may be of interest to developing countries who want to achieve universal health insurance while maintaining a significant role for the private sector.     

Consider it done? The likely efficacy of mandates for health insurance

Several health insurance reform plans, including the recently enacted Massachusetts plan, envision the use of individual or employer mandates to increase coverage rates. In this paper we summarize and analyze existing evidence on the effectiveness of mandates, drawing on evidence both from health insurance and from other arenas where mandates are often used. We find that mandates can, but do not always, increase participation in programs. The effectiveness of a mandate depends critically on the cost of compliance, the penalties for noncompliance, and the timely enforcement of compliance.     

The national health service plan: further reform of British health care?

Less than three years after initiating a series of health service reforms, the Blair government has launched another plan for the U.K. National Health Service. This article considers the origins and contents of the plan. A major investment program is designed to bring health care spending up to European averages over the next five years. In return, the government seeks to challenge the existing settlement between organized medicine and the state through tighter regulatory control, altered contractual frameworks, and a new public-private concordat. The plan does not represent a radical change in government policy but rather reaffirms existing approaches to increasing access to health services, integrating health and social care, and empowering users. Notwithstanding arrangements to increase the autonomy of health service organizations, the plan increases central control through a range of new bodies and regulatory frameworks. It represents an incremental adjustment of the existing tax-funded system. Should this reinvigoration of the state monopoly fail, alternative sources of funding will no doubt have to be reconsidered.     

Do Mexican immigrants substitute health care in Mexico for health insurance in the United States? The role of distance

Although language and culture are important contributors to uninsurance among immigrants, one important contributor may have been overlooked - the ability of immigrants to return to their home country for health care. This paper examines the extent to which uninsurance (private insurance and Medicaid) is related to the ability of immigrants to return to Mexico for health care, as measured by spatial proximity. The data for this study are from the Mexican Migration Project. After controlling for household income, acculturation and demographic characteristics, arc distance to the place of origin plays a role in explaining uninsurance rates. Distance within Mexico is quite important, indicating that immigrants from the South of Mexico are more likely to seek care in their communities of origin (hometowns).     

Commercial health insurance: smart or simply lucky?

Changes in the commercial health insurance industry are less a strategic shift than a defensive reaction to forces the industry cannot control and risky opportunities the industry cannot pass up. Diversification into the public sector presents short-term gains for the insurance industry but leaves unchanged the fundamental challenge it faces: rapid and apparently uncontrollable growth in health care costs. Commercial insurers have not proved to be any better than public payers at controlling costs. Unfortunately, unless the drivers of health care cost are tamed, the main benefits that people seek from insurance-stable coverage and financial protection--will erode further.