A national long-term care program for the United States. A caring vision. The Working Group on Long-term Care Program Design, Physicians for a National Health Program.

The financing and delivery of long-term care (LTC) need substantial reform. Many cannot afford essential services; age restrictions often arbitrarily limit access for the nonelderly, although more than a third of those needing care are under 65 years old; Medicaid, the principal third-party payer for LTC, is biased toward nursing home care and discourages independent living; informal care provided by relatives and friends, the only assistance used by 70% of those needing LTC, is neither supported nor encouraged; and insurance coverage often excludes critically important services that fall outside narrow definitions of medically necessary care. We describe an LTC program designed as an integral component of the national health program advanced by Physicians for a National Health Program. Everyone would be covered for all medically and socially necessary services under a single public plan, federally mandated and funded but administered locally. An LTC payment board in each state would contract directly with providers through a network of local public agencies responsible for eligibility determination and care coordination. Nursing homes, home care agencies, and other institutional providers would be paid a global budget to cover all operating costs and would not bill on a per-patient basis. Alternatively, integrated provider organizations could receive a capitation fee to cover a broad range of LTC and acute care services. Individual practitioners could continue to be paid on a fee-for-service basis or could receive salaries from institutional providers. Support for innovation, training of LTC personnel, and monitoring of the quality of care would be greatly augmented. For-profit providers would be compensated for past investments and phased out. Our program would add between $18 billion and $23.5 billion annually to current spending on LTC. Polls indicate that a majority of Americans want such a program and are willing to pay earmarked taxes to support it.     

Including the poor: the fiscal impacts of Medicaid expansion

This article presents the fiscal impacts of the comprehensive reform of the Medicaid program put forth by the Health Policy Agenda for the American People. Proposed reforms include establishment of improved uniform eligibility standards, improvement in the scope and depth of coverage in state Medicaid programs, and increased provider payment rates. We estimate that expanding Medicaid coverage to all currently uninsured nonelderly persons below the federal poverty line would cost approximately $9 billion. A substantial portion of these costs would offset current spending elsewhere in the health care system. Improvement of state packages and increased provider payment could result in sharp increases in costs. We provide a range of estimates considering both the set of benefits provided and the behavior of the private insurance market.     

Health USA. A national health program for the United States.

The Health USA Act of 1991 addresses two fundamental health services financing problems: the more than 30 million uninsured persons and the rising costs for health care and for health insurance. Health USA would provide coverage of the entire resident population for comprehensive medical and preventive health and long-term care services through a universal tax-funded financing system. The federal government would contribute an average of 87% of program costs to each state, which would establish, under federal guidelines, a state health program. Each individual or family may enroll in any health plan approved by the state program, including many private plans, or a plan run by the state program. Through the approved plan of their choice, enrollees would receive covered services and obtain their care from participating physicians and other professional practitioners, hospitals, and other facilities. The state program would pay approved plans a capitation payment for every person enrolled. The plans would pay professional providers fees, as part of an all-payer system of fee schedules and expenditure targets, or capitation payments or salary. Hospitals would be financed through global budgets negotiated by the state program with each hospital. The plan run by the state program would pay the health care costs of any person who does not enroll in an approved plan, making the state plan the payer of last resort and eliminating uncompensated care and cost shifting by providers. Health USA would separate health care coverage from employment, ensuring uninterrupted coverage and eliminating employers' administrative role in providing coverage. Federal and state taxes would replace present methods of financing by private insurance premiums and large out-of-pocket expenditures. Building on the present system of health plans, Health USA would offer all persons a wide choice of competing plans in which to enroll and offer professional providers a wide choice of plans in which to practice. It would control costs by increasing financial accountability of providers and health plans, reducing present reliance on intrusive utilization review and on patient cost sharing. By controlling health care and administrative costs, Health USA would cover the entire population and, according to independent cost estimates, reduce national health expenditures by $11.5 billion in 1991.     

A call for action. The Pepper Commission's blueprint for health care reform

After a year of deliberation and investigation, the Pepper Commission recommended action to ensure that all Americans would have health insurance protection in an efficient, effective health care system. Because it believes that action is urgent, the commission would build universal coverage by securing, improving, and extending the combination of job-based and public coverage we now have. Reform would entail the following elements: a combination of incentives and requirements that would guarantee all workers (with their nonworking dependents) insurance coverage through their jobs; replacement of Medicaid with a new federal program that would cover all those not covered through the workplace and workers whose employers find public coverage more affordable; guaranteed affordable coverage for employers--through reform of private insurance, tax credits for small employers, and the opportunity to purchase public coverage; a minimum benefit standard for private and public plans that would cover preventive and primary services as well as catastrophic care and would include cost sharing, subject to ability to pay; and a combination of public and private sector initiatives to promote quality and contain costs.     

Social health insurance and drug spending a mong cancer inpatients in China

A social health insurance(SHI) program has been established in China to ensure that people can obtain health care economically and equitably. Our analysis indicates that in 2005-06, 66.5 percent of Chinese citizens were non-SHI inpatients. We also found that drug spending for SHI inpatients was significantly higher than that for non-SHI inpatients. After adjusting for other variables, we found that the SHI coverage was also associated positively with higher drug costs. We present evidence to show that drug spending differences are attributable at least in part to differences in insurance courage.     

The taxes of sin. Do smokers and drinkers pay their way?

We estimate the lifetime, discounted costs that smokers and drinkers impose on others through collectively financed health insurance, pensions, disability insurance, group life insurance, fires, motor-vehicle accidents, and the criminal justice system. Although nonsmokers subsidize smokers' medical care and group life insurance, smokers subsidize nonsmokers' pensions and nursing home payments. On balance, smokers probably pay their way at the current level of excise taxes on cigarettes; but one may, nonetheless, wish to raise those taxes to reduce the number of adolescent smokers. In contrast, drinkers do not pay their way: current excise taxes on alcohol cover only about half the costs imposed on others.     

Beyond universal health insurance to effective health care

The history of the U.S. governmental health care reform indicates that efforts toward universal health insurance cannot be expected from a financially strapped federal government. Ambitious governmental programs such as veterans' services and Medicaid have encountered accessibility problems associated with location, arbitrary limitations of reimbursement criteria, and opposition from taxpayers due to the higher taxes and premiums necessitated by program reform. Nonfinancial obstacles to access include physicians migration away from minorities and the poor, the strained conditions of many public hospitals, and immigrants' isolation due to language barriers and paranoia over citizenship status. Ginzberg presents interim targets for the expansion of access to health care: the expansion of Medicaid, subsidized coverage for the near poor, private sector catastrophic insurance policies, expansion of the Federal Community Health Center program, expansion of the National Health Service Corps and State Educational Debt Forgiveness Programs, and state subsidies for uncompensated care.     

The Physicians Who Care plan. Preserving quality and equitability in American medicine

To expand health care to all Americans, the organization Physicians Who Care favors a reshaping of current U.S. health care financing structures in preference to a national health care program like Canada's. The proposal comes in five parts. First, Bronow, et al. suggest mandatory employer-provided basic coverage with high deductibles. Second, for people of limited means, high deductibles can be substituted by individual medical savings accounts, established with pretax dollars. Third, instead of being funded entirely through taxes each year, Medicare could be funded partly through medical IRAs, required for every American from his or her first year of life. Fourth, long-term care should be taken out of Medicaid, and eligibility requirements should be changed. Finally, instead of allowing insurance companies to set health benefits, scientific guidelines should be established for medical care. Bronow, et al. also recommend that patients be made fully aware of any financial incentives for physicians.     

Is the Turkish Health Care System Ready to Be a Part of the European Union?

Lately, Turkey is struggling to recover from the economic effects of the economic crisis so that the government officials are trying to impose budget cuts in health and education sectors. After the United States, the country's national defense expenditures are the highest among the NATO countries. Therefore, Turkey allocates only 3–4% of the gross domestic product for health care expenses. Overall, the health status in Turkey is the lowest among the European Union countries; infant mortality rate is about 45 per 1000 live births, which is the highest on the European continent, and per capita health care expenditure is $120. Although 75% of the people are covered by some type of public insurance, 25% of the Turkish people do not have any insurance coverage. The national system is funded by taxes (43%), out of pocket payments (32%), and social and private insurance premiums (25%). This study examines whether Turkey is ready to be a part of the European Union in terms of the health sector of its economy and health status of its people.     

韩国医疗保险制度的改革及对我国的启示

韩国医疗保险制度在实现基本医疗全民覆盖和有效控制医疗成本方面取得了重大进展,但人口迅速老龄化和国家医保覆盖面扩大所带来的医疗费用过快上涨、提供服务的公平性等问题仍使韩国面临前所未有的挑战.为解决上述问题,韩国政府采取了支付制度改革、降低药品支出、促进健康老龄化等一系列改革措施.本文总结了韩国医疗保险制度的基本特点,其经验对我国医疗保险制度改革具有宝贵的借鉴意义.     

Health spending,illicit financial flows and tax incentives in Malawi

This analysis examines the gaps in health care financing in Malawi and how foregone taxes could fill these gaps. It begins with an assessment of the disease burden and government health expenditure. Then it analyses the tax revenues foregone by the government of Malawi by two main routes

• Illicit financial flows (IFF) from the country
• Tax incentives.

We find that there are significant financing gaps in the health sector; for example, government expenditure is United States Dollars (USD) 177 million for 2013/2014 while projected donor contribution in 2013/2014 is USD 207 million and the total cost for the minimal health package is USD 535 million. Thus the funding gap between the government budget for health and the required spending to provide the minimal package for 2013/2014 is USD 358 million. On the other hand we estimate that almost USD 400million is lost through IFF and corporate utilization of tax incentives each year.The revenues foregone plus the current government health spending would be sufficient to cover the minimal public health package for all Malawians and would help tackle Malawi''s disease burden. Every effort must be made, including improving transparency and revising laws, to curtail IFF and moderate tax incentives.     

An American approach to health system reform

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)     

The public's view of the future of health care

An analysis of more than two decades of poll results has identified six major trends in public opinion likely to affect the health care system of the 1990s. Americans favor more rather than less health spending, at least as long as the economy remains strong, and they do not think the deficit problem requires cuts in medical care outlays. Should there be a serious economic downturn, however, the public would reverse itself and would favor reduced spending that relies on a different set of strategies than those favored by most health policy experts, particularly in regard to spending for care for the elderly. In either case, the poll results suggest that Americans may be less inclined to participate in newer forms of medical practice, such as health maintenance organizations or preferred provider organizations, than anticipated, and that the commercialization of health care is leading to a decline in public confidence in the leaders of medicine. This latter trend may result in a lack of trust in professionals' views concerning the quality of care and may presage more stringent government involvement in and regulation of health services.     

Health care institutions: survival in a changing environment

The health care system in the United States has been altered by recent economic and political events, including a major recession and a retrenchment in federal nonentitlement spending programs. The economic recovery and the continuing high federal deficits prompt new questions about both the future expansion and the distribution of health spending. Long-term economic forecasts and public opinion polls suggest that health will consume a growing share of the national resources. Nevertheless, the level of health spending will not grow as rapidly as in the past, and the distribution of that spending may also change. Because of these changes, the growth in health spending will not guarantee the survival of existing institutions. New competitive forces and revised reimbursement mechanisms will lead to a redistribution of the health dollar, and this redistribution will create both risk and opportunity for America's important health care institutions and their health professionals.     

Proposal of the Physicians' Working Group for Single-Payer National Health Insurance

The Physicians' Working Group for Single-Payer National Health Insurance^*

JAMA. 2003;290:798-805.

The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care—the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least $200 billion annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage.

     

National health insurance: A new imperative

When viewed from the perspective of the policy analyst, observed inequities in the access to health services and the rising costs of physician and hospital care are among the most important issues confronting the American health delivery system. Recognizing that publicly financed health insurance programs result in a more equitable distribution of medical services, this paper focuses on the components of a national health insurance scheme that not only offers a comprehensive range of benefits but also employs prospective payment and a set of financial incentives to control the costs of care provided by physicians, hospitals, and other health facilities. The national health insurance program proposed in this paper is designed to eliminate or reduce unwarranted expenditures on plant and equipment; the responsibility for approving and funding capital acquisitions is also regarded as an integral component of the program.     

Ten years of mental health service reform in Australia: are we getting it right?

We summarise the most recent data available on changes to the public and private mental health sectors from the commencement of the National Mental Health Strategy in 1993 to 2002. There has been substantial service system change in the directions agreed by governments under the Strategy, supported by a 65% growth in government spending on mental health. Despite this there is growing public and professional concern about deficiencies in the mental health service system. We review the current call for change in light of increased community expectations and growth in demand for services. Given broad national and international support for Australia's policy directions, the problems lie with the pace and extent of change and ensuring better outcomes from the increased investment in mental health care.     

The Health Security Partnership. A federal-state universal insurance and cost-containment program

The Health Security Partnership attempts to assure (1) that all Americans have insurance coverage for a set of comprehensive health care benefits, (2) that cost-containment issues are addressed in a manner that does not impinge negatively on the quality of care, and (3) that provider freedom to deliver appropriate clinical care is strengthened. It assigns important responsibilities to the federal government (eg, specification of benefits, review of proposed state health care budgets), while permitting states to select, develop, and administer specific program design features they deem appropriate (eg, states could build on and expand the existing health system infrastructure, including private insurance, and/or extend the role of tax-supported programs). It is estimated that in its first year the program would add about 5% to America's health expenditures, but within a few years, cost-containment efforts and administrative efficiencies would reduce overall expenditures below what they otherwise would be.     

The uninsured and the debate over the repeal of the Massachusetts universal health care law.

OBJECTIVES--The debate in Massachusetts over the repeal of the first state-based "pay or play" universal health plan is discussed using data from a survey of 1066 Massachusetts households. The survey attempted to measure the problems of the uninsured, to estimate the likelihood that they would buy insurance if offered, and to calculate the proportion of the uninsured who would be covered under an employer mandate. DESIGN--A survey conducted in person and by telephone in 1066 households, with an oversample of uninsured households, using stratification, clustering, disproportionate sampling, and poststatistical weighting. PARTICIPANTS--Adults aged 18 years and older who were knowledgeable about the insurance status of persons in their household. MAIN OUTCOME MEASURES--Insurance status, employment status, access to and use of health services, and willingness to purchase health insurance. RESULTS--First, the present system of hospital-based uncompensated care in Massachusetts is inadequate by itself to meet the needs of uninsured residents. Uninsured persons are less likely than insured ones to seek medical care for chronic health problems and serious symptoms requiring evaluation. Second, 83% of uninsured families and 24% of uninsured individual respondents would purchase one of several insurance options with 30% of the cost subsidized. Last, the employer mandate provisions of the legislation would cover 43% of the uninsured in Massachusetts. CONCLUSION--In the current economic climate, the political viability of the universal health care plan and similar national initiatives is uncertain given the intractable conflict between perceptions of the financial stability of small businesses that do not offer insurance and the health care needs of uninsured individuals.     

The 'USHealth Act'. Comprehensive reform for a caring America

USHealth is a program proposed by Congressman Roybal to provide catastrophic and basic health coverage for all Americans, regardless of age, income, or illness. It would be managed by the USHealth Administration, an independent off-budget government agency, and would consolidate Medicare, Medicaid, and private insurance into a single insurance program. Roybal argues the case for his proposal, focusing on cost-containment; the expansion of coverage to include nursing and long-term care; the prioritization of quality assurance; financing along the lines of the current Medicare model; and commitment to "true" criteria: protection of the uninsured, protection of underinsured working families, short-term catastrophic protection for underinsured persons, containment of health care costs, assurance of quality care, and full financing now and in the foreseeable future.