Socialized medicine: a solution to the cost crisis in health care in the United States

Despite growing concern with cost containment, most health policy analysts have ignored vast potential savings on medically irrelevant spending for excess administration, profits, high physician incomes, marketing, and legal involvement in medicine. Indeed, many recent reforms encourage administrative hypertrophy, entrepreneurialism and litigation. A universal national health program could abolish billing and consequently the need for much of the administrative apparatus of health care, and decrease spending for profits and marketing. In this article we analyze the administrative savings that could be realized from instituting a Canadian-style national health insurance program or a national health service similar to that in Britain, and the potential savings from additional reforms to curtail profits, marketing and litigation. Our calculations based on 1983 data suggest that national health insurance would save $42.6 billion annually: $29.2 billion on health administration and insurance overhead, $4.9 billion on profits, $3.9 billion on marketing, and $4.6 billion on physician's incomes. A national health service would save $65.8 billion: $38.4 billion on health administration and insurance overhead, $4.9 billion on profits, $3.9 billion on marketing, and $18.6 billion on physician's incomes. Complete nationalization of all health related industries and reform of the malpractice system would save at least $87.2 billion per year. We conclude that a national health program, in addition to improving access to health care for the oppressed, could achieve cost containment without rationing of care.     

Group Practice in Occupational Medicine

Unions have been formed to improve economic standards of employees and occupational health, have subsequently pressed for family health services, and have achieved group medical practice coverage in many areas. In the process of industrialization in America, workmen’s compensation legislation was introduced as an employee benefit in a separate stream of development; thus, the current separation of health services into two systems-occupational and general medical care. This separation, while still justified today, can eventually be eliminated under a national health insurance scheme guaranteeing all health care as a right, including the care of workers injured on the job. This would leave to employers and employees, working in cooperation with technical experts, the task of improving working conditions so that job-related injury and illness may eventually be eliminated.     

异地就诊医保核算监督机制的完善对于医保体系高效化管理的意义

目的 探讨异地医保稽核制度的完善对于提高医保体系效率的意义.方法 通过对我国现行异地医保的稽核方式存在的漏洞和弊端进行分析,同时提出加强监督的相关建议.结果 目前异地医保稽核方式存在着实施困难、网络不健全、各地区之间合作性差,合作标准不统一等弊端,需要不断加强网络建设、建立全国性的医疗记录登记、实施全国统一的医保政策、甚至建立统一的医保体系等是进一步加强医保监督机制的有效措施.结论 健全的监督机制对于提高异地就医结算的的审核效率、审核意义重大.     

Health technology assessment in The Netherlands

The Dutch healthcare system is not a single overall plan, but has evolved from a constantly changing mix of institutions, regulations, and responsibilities. The resulting system provides high-quality care with reasonable efficiency and equal distribution over the population. Every Dutch citizen is entitled to health care. Health insurance is provided by a mix of compulsory national insurance and public and private insurance schemes. Hospitals generally have a private legal basis but are heavily regulated. Supraregional planning of high-tech medical services is also regulated. Hospitals function under fixed, prospective budgets with regulation of capital investments. Independent general practitioners serve a gatekeeper role for specialist and hospital services and are paid by capitation or fee for service. Specialists are paid by fee for service. All physicians' fees are controlled by the Ministry of Economic Affairs. Coverage of benefits is an important method of controlling the cost of services. There is increasing concern about health care quality. Health technology assessment (HTA) has become increasingly visible during the last 15 years. A special national fund for HTA, set up in 1988, has led to many formal and informal changes. HTA has evolved from a research activity into policy research for improving health care on the national level. In 1993 the government stated formally that enhancing effectiveness in health care was one of its prime targets and that HTA would be a prime tool for this purpose. The most important current issue is coordination of HTA activities, which is now undertaken by a new platform representing the important actors in health care and HTA.     

Crossroads in quality

Expanding insurance coverage is a critical step in health reform, but we argue that to be successful, reforms must also address the underlying problems of quality and cost. We identify five fundamental building blocks for a high-performance health system and urge action to create a national center for effectiveness research, develop models of accountable health care entities capable of providing integrated and coordinated care, develop payment models to reward high-value care, develop a national strategy for performance measurement, and pursue a multistakeholder approach to improving population health.     

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.     

新医改形势下看病难、看病贵的表现形式、根源与对策

看病难看病贵因国家形态、历史时期、社会阶层的不同而呈现不同的表现形式。看病难源于医疗服务供给总量不足与结构失衡;看病贵源于医疗服务价格的扭曲与医疗保险体系的残缺,看病难看病贵的感受差异根源于社会阶层的高低。解决看病难与看病贵的治本之策是通过公共卫生与健康管理控制医疗服务的需求;治标之策是扩大供给总量、调整供给结构与提高医疗保险的保障水平与保障范围。中国未来的看病难、贵主要体现为特需医疗服务的看病难、贵,必须从特需医疗服务供给与商业医疗保险建设两个方面加以解决。     

从三个公平的视角认识医疗保险城乡统筹

随着经济社会的持续发展,国民对社会公平诉求越来越强烈。推进城乡统筹是实现权利公平、机会公平、规则公平的有效途径,在医疗保险上尤为如此,医疗保险城乡统筹是三个公平的集中体现,通过消除隐性的不公平,实现“公平医保”的实质公平。从实现的路径来看主要通过一制多档,统一管理、经办,共享信息,提高统筹层次等途径逐渐实现医疗保险城乡统筹。     

Women and Health Reform: How National Health Care Can Enhance Coverage,Affordability, and Access for Women (Examples From Massachusetts)

BackgroundMassachusetts women have the highest rates of health insurance coverage in the nation and women's access to care has improved across all demographic groups. However, important challenges persist. As national health reform implementation moves forward under the Affordable Care Act (ACA), states will likely encounter many of the same women's health challenges experienced in Massachusetts over the past 7 years.MethodsA review of the literature and data analyses comparing health care services access, utilization, and cost, and health outcomes from Massachusetts pre- and post-2006 health care reform identified two key challenges in women's continuity of coverage and affordability.ConclusionThese areas are crucial for state and national policymakers to consider in improving women's health as they work to implement health care reform at the state and federal levels.     

The potential role of risk-equalization mechanisms in health insurance: the case of South Africa

International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk-equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer.     

Insights from health care in Germany

German Statutory Health Insurance (national health insurance) has remained relatively intact over the past century, even in the face of governmental change and recent reforms. The overall story of German national health insurance is one of political compromise and successful implementation of communitarian values. Several key lessons from the German experience can be applied to the American health care system.     

The role of health insurance in the growth of the private health sector in Korea

The Korean health care system has been recognized by other countries for its rapid expansion of national health insurance. The government's policy of promoting the private sector, relying on market forces for various allocation decisions, and using the fee-for-service payment system has created a number of challenges for the Korean health system. Among these are rapid growth of health care expenditure, proliferation and duplication of medical technology, and lack of access for low-income groups due to high out-of-pocket payments for services covered by insurance. A number of recommendations are made concerning national health policy, modifying health insurance, and developing political consensus for bringing about health reform.     

Will uninsured people volunteer for voluntary health insurance? Experience from Washington State.

OBJECTIVES: In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should be mandatory or voluntary. This study describes characteristics of low- income people who were more likely or less likely to be covered by a voluntary plan. METHODS: Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics. RESULTS: There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance. CONCLUSIONS: If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care.     

Individual health accounts: an alternative health care financing approach.

After examining the major determinants of inefficiency in health care markets and several recent proposals to correct these problems, this paper introduces a market-oriented alternative which could be highly efficient while meeting all the established goals of a national health plan. To achieve these objectives, traditional forms of insurance would be replaced by a system with the following characteristics: (1) instead of buying insurance, individuals and their employers would be required to contribute into individual health accounts from which each family would pay for medical care; (2) Once accumulations attain a designated level, any excess accumulations are distributed to the individual; and (3) A national health fund is established to support those without regular accumulations or those whose accounts have been depleted. This paper develops these principles to show how everyone would have access to care as well as the financial security normally associated with comprehensive insurance. But, by inducing many patients to behave as if they were paying for the full cost of care through reductions in potential earnings from their accounts, the paper explains how significant savings in total spending could also be achieved.     

实施“农民健康工程”发展农村卫生事业

该文对山西省农村卫生工作做了大量调查,主要有4方面问题。1.农村三级医疗保健网基础设施建设严重滞后,工作用房维修改扩建任务重;2.乡镇卫生院设备陈旧落后,难以适应当前医疗卫生服务需要;3.乡村两级卫技人员素质偏低;4.有一定比例国家级和省级贫困县。因病致贫、因病返贫占贫困户的比例较大。针对以上问题,省委、省府把加强和完善农村三级医疗预防保健网建设、普及合作医疗和提高农村卫技人员素质作为“农民健康工程”来抓,其主要措施为：1．农村三级医疗预防保健网建设,到2000年全部实现“一无三配套”;2．普及农村合作医疗,到2000年全省80％以上的村卫生所要实现各种形式的合作医疗;3.乡村两级卫技人员培训,到2000年现乡、村两级无专业学历的卫技人员中80％以上要接受正规医学中专学历教育。     

Health insurance coverage-enrollment and adequacy of prenatal care utilization.

Most studies have concluded that good prenatal care plays an essential role in improving birth outcomes, and numerous reports have documented barriers to adequate prenatal care. The relationship between health care insurance eligibility and enrollment procedures and adequacy of prenatal care, however, has not been suitably investigated. This study used data from a statewide representative sample of recently delivered women in South Carolina to assess (1) patterns of health care insurance source and (2) the independent effects of Medicaid enrollment and application procedures on receipt of prenatal care. Health insurance during pregnancy varied by sociodemographic characteristics. Black women's experiences with Medicaid enrollment and application procedures were associated with less than adequate prenatal care. Programmatic efforts and policies should emphasize further improvement in the systems of health care access and delivery to disadvantaged women.     

Current research perspectives of health system research and health economics in Germany

The German statutory health insurance scheme is confronted with a steadily rapid progress of medical sciences and increasing difficulties to mobilize the financial resources necessary for applying the new scientific knowledge in health care. Therefore it is absolutely imperative to intensify the efforts to improve the effectiveness and efficiency of health care. Health policies based on health targets, the development of patterns requiring integrated care, redefining the bunch of health insurance benefits, and a more regular use of methods of economic evaluation have been proposed as promising approaches towards optimizing resource allocation in health care. However, an analysis of these approaches demonstrates that a valid appraisal of their potential to improve the effectiveness and efficiency of health care requires further research. In addition, European integration may produce tendencies towards a convergence of the national health care systems; this makes it rather difficult to assess how the room for autonomous national health policies will develop in the future.     

Is 'moral hazard' inefficient? The policy implications of a new theory

"Moral hazard" refers to the additional health care that is purchased when persons become insured. Under conventional theory, health economists regard these additional health care purchases as inefficient because they represent care that is worth less to consumers than it costs to produce. A new theory, however, suggests that much of moral hazard is actually efficient. When the care that was deemed to be welfare-decreasing is reclassified as welfare-increasing, health insurance becomes much more valuable to consumers than health economists have hitherto thought it was. As a result, there is a new argument for national health insurance: efficiency.     

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.