The U.S. health insurance industry: an alternative view.

The health insurance industry in the U.S. can be characterized as a concentrated industry. It has evolved into its current structure as a result of certain historical conditions, particularly those following the Great Depression. The structure of the industry has had an effect on the manner in which the industry functions and the cost increases in the health care sector. Specifically, the pricing mechanism is that of a price leader setting a limit price; health premium prices are higher than would be expected under a competitive structure. Regulation has been ineffective, because it has been dominated historically by health care providers and insurers. The costs of health care in general, and hospital care in particular, have increased beyond what would be expected as a result of "cost-pass-through."     

美国医保“私有化”之争

在4700万人没有医疗保险的当今美国，政府对医疗保险的开支已经失控。卫生与公众服务部预计，如果任其发展下去，医疗开支到2017年几乎会翻一番，达到4．3万亿美元，占国内生产总值的20％，而现在是16％。     

Myths and misconceptions about U.S. health insurance

Several myths about health insurance interfere with the diagnosis of problems in the current system and impede the development of productive reforms. Although many are built on a kernel of truth, complicated issues are often simplified to the point of being false or misleading. Several stem from the conflation of health, health care, and health insurance, while others attempt to use economic arguments to justify normative preferences. We apply a combination of economic principles and lessons from empirical research to examine the policy problems that underlie the myths and focus attention on addressing these fundamental challenges.     

Public light and private dark: the privatization of home health services for the elderly in the U.S

The privatization of health care has been a controversial topic that has consumed an increasing share of national attention in both the United Kingdom and the United States. In this paper we consider several definitions of privatization; outline two strategies of privatization--privatization by replacement and privatization by reduction or attrition; identify possible consequences of various policies of privatization for health and social services for the elderly; and offer some ideas about how trends toward privatization may be assessed, utilizing empirical data from research on the impact of medical cost containment and privatization on community-based services in the U.S. That the substance of government policy is moving toward privatization is without question; that these policies may have serious consequences for outcomes of social equity is still under debate. The trends suggested in our research have potentially negative consequences for marginal elderly clients in U.S. If the consequences of privatization can be linked to the denial of service to needy clients, privatization may, indeed, represent a dark alternative to the welfare state.     

The availability of reproductive health services from U.S. private physicians

Data on the provision of seven types of reproductive health care were collected from private physicians in four specialties: general/family practitioners (GP/FPs), general surgeons, obstetrician-gynecologists and urologists. All ob-gyns, and eight in 10 GP/FPs, provide the pill, IUD or diaphragm. Over nine in 10 ob-gyns provide infertility and obstetric care and prenatal genetic screening; but only one-third or fewer of GP/FPs do so. Ob-gyns and urologists are far more likely to perform sterilizations than are GP/FPs and surgeons (nine in 10, compared with one-fifth to one-half). Although ob-gyns are the most likely to perform abortions, only four in 10 do so. Among ob-gyns who do not perform tubal sterilizations or abortions, and among urologists who do not perform vasectomies, the primary reason is moral or religious objections (reported by 59-71 percent). For GP/FPs and surgeons who do not perform the three procedures, the leading reason is that they do not perform surgery or that type of surgery; however, 34 percent of nonproviders in these specialties report moral or religious opposition to abortion. Eight in 10 ob-gyns will provide contraceptives to minors without parental consent, but only six in 10 GP/FPs will do so. One-half of doctors who perform female sterilizations, and eight in 10 of those who do vasectomies, require spousal consent. Among those who perform abortions, half require parental consent for minors. Access to private reproductive health care is quite limited for the poor, because many physicians will not accept Medicaid reimbursements or reduce their fees for low-income patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Universal health insurance and high-risk groups in West Germany: implications for U.S. health policy

Access to West Germany's broad-based health-insurance system is geared to the country's occupational structure. People who qualify, however, may seek coverage from alternative sources, including local "sickness funds." The changing nature of the German job market is leading to concentration of high-risk groups in the local funds, some of which could in turn face serious financial problems. Proponents of a universal health-insurance program for the United States need to take account of the growing segmentation of risk groups in the current German experience, which may ultimately threaten the concept of solidarity on which the system is founded.     

Criteria for the future division of labor between private and social health insurance

This article's point of departure is that the individual has to manage three stochastic assets, namely health, wealth, and wisdom (skills), which tend to be positively correlated. It shows that the unexpected components of insurance payments should be negatively correlated for minimizing total asset volatility. The empirical finding is that in the United States, Japan, and Germany, the lines of social insurance contribute less to diversification than do those of private insurance. The article concludes with suggestions for new, umbrella-type insurance contracts that in the future should help individuals in the efficient management of their assets.     

The public/private mix and human resources for health

This paper examines the general question of the public/private mix in health care, with special emphasis on its implications for human resources. After a brief conceptual exercise to clarify these terms, we place the problem of human resources in the context of the growing complexity of health systems. We next move to an analysis of potential policy alternatives. Unfortunately, a lot of the public/private debate has looked only at the pragmatic aspects of such alternatives. Each of them, however, reflects a specific set of values--an ideology--that must be made explicit. For this reason, we outline the value assumptions of the four major principles to allocate resources for health care: purchasing power, poverty, socially perceived priority, and citizenship. Finally, the last section discusses some of the policy options that health care systems face today, with respect to the combinations of public and private financing and delivery of services. The conclusion is that we need to move away from false dichotomies and dilemmas as we search for creative ways of combining the best of the state and the market in order to replace polarized with pluralistic systems. The paper is based on a fundamental premise: The way we deal with the question of the public/private mix will largely determine the shape of health care in the next century.     

The demand for private health care under national health insurance

This study explores the demand for private health care and supplemental health insurance in Israel, where universal national health insurance provides all inhabitants with a standard package of medical care. Our theoretical model and empirical study follow research previously conducted in four other countries. It was found that the self-employed in Israel demand more private health services and supplemental health insurance than wage-earners. Income, age, education, health status, marital status, origin, and profession were found to play a part in explaining these demands.     

Socioeconomic factors and Medicare supplemental health insurance.

This analysis was conducted to determine how personal and community characteristics affect coverage by private insurance to supplement Medicare. Data from the 1980 National Medical Care Utilization and Expenditure Survey were used. After controlling for health status, it was found that supplemental coverage was positively associated with education, income, number of self-reported chronic conditions, being white, being married, and having a regular source of care. Private coverage was negatively associated with Medicaid coverage and age. The only community characteristic associated with supplemental coverage was region. Consideration of local medical resources and economic measures did not change that.     

Combined social and private health insurance versus catastrophic out of pocket payments for private hospital care in Greece

The high level of out of pocket (OOP) payments constitutes a major concern for Greece and several other European and OECD countries as a result of the significant down turning of their public health finances due to the 2008 financial crisis. The basic objective of this study is to provide empirical evidence on the effect of combining social health insurance (SHI) and private health insurance (PHI) on OOP payments. Further, this study examines the catastrophic impact of OOP payments on insured’s welfare using the incidence and intensity methodological approach of measuring catastrophic health care expenditures. Conducting a cross-sectional survey in Greece in 2013, we find that the combination of SHI–PHI has a strong negative influence on insured OOP payments for inpatient health care in private hospitals. Furthermore, our results indicate that SHI coverage is not sufficient by itself to manage with this issue. Moreover, we find that poor people present a greater tendency to incur catastrophic OOP expenditures for hospital health care in private providers. Drawing evidence from Greece, a country with huge fiscal problems that has suffered the consequences of the economic crisis more than any other, could be a starting point for policymakers to consider the perspective of SHI–PHI co-operation against OOP payments more seriously.     

Cost sharing, supplementary insurance, and health services utilization among the Medicare elderly.

This paper investigates the extent to which private supplementary insurance and Medicaid, which vitiate the effect of Medicare cost-sharing, encourage elderly beneficiaries to seek additional medical care. A multivariate model of health services utilization is estimated with the Tobit technique, using the 1976 Health Interview Survey. We find that either private or public supplementation induces greater use of hospital and physician services, though in amounts that vary considerably according to health status. The paper closes with observations on cost savings brought about by Medicare cost-sharing and some implications for equity among beneficiaries.     

Sources of health insurance in the U.S.: analysis of state-level data and implications for public health programs.

Lack of health insurance coverage is associated with lack of accessibility to preventive health care services such as mammography screening, clinical breast examination, Papanicolaou smear test, digital rectal examination, proctoscopy examination, and cholesterol screening. State and federal public health agencies must have an understanding of insurance coverage of the population to plan intervention programs aimed at early detection of medical conditions. Using data from the March Supplement of the Current Population Survey for the years 1994, 1995, and 1996, this study examines the sources of health insurance coverage in the U.S. The implications of the findings for public health programs are discussed.     

State variation in health insurance coverage for U.S. citizen children of immigrants

In this paper we compare health insurance coverage for U.S. citizen children in all-citizen and mixed families in the fifteen states with the largest share of children in mixed families. Insurance coverage is lower and state variation in coverage is higher for children in mixed families vis-à-vis children in all-citizen families. The main challenges for states are tackling uninsurance among all low-income children and addressing the very low rates of employer-sponsored insurance for all low-income children and for children in all mixed families, regardless of income. We discuss state policy options to address the needs of children in mixed families.     

The U.S. economy and changes in health insurance coverage, 2000-2006

The number of uninsured Americans increased by 3.4 million between 2004 and 2006, despite improving economic conditions. In the first four years of the decade, during a period of economic recession, the number increased by 6.0 million. The dominant factor in both periods was a decline in employer-sponsored insurance coverage. Although the recent decline was less than that experienced from 2000 to 2004, growth in public coverage was small, and the number of uninsured people increased by 1.0 million children and 2.4 million adults. Employer coverage declined most for self-employed or small-firm workers, in the South, and among noncitizens.     

Historical and comparative reflections on the U.S. national health insurance reforms

The 2010 US reforms addressed forms of public and private insurance designed to reinforce a delivery system that developed to maximize the autonomy of physicians and hospitals. That autonomy emphasizes fees and specialization, which led to for-profit incorporation and overtreatment. Powerful corporate lobbies have defeated previous reforms and diluted the impact of the Obama reform. It barely passed and does little to manage costs or rationalize medicine. US health care does not fit established models of welfare states and contains five different models of health care delivery. Most interesting are forms of democratically run community health centres. Selected features of the reforms are highlighted.     

Designing health insurance information for the Medicare beneficiary: a policy synthesis.

Can Medicare beneficiaries make rational and informed decisions about their coverage under the Medicare program? Recent policy developments in the Medicare program have been based on the theory of competition in medical care. One of the key assumptions of the competitive model is the free flow of adequate information, enabling the consumer to make an informed choice from among the various sellers of a particular product. Options for Medicare beneficiaries in supplementing their basic Medicare coverage include the purchase of private supplementary insurance policies or enrollment in a Medicare HMO. These consumers, in a complex health insurance market, have only limited information available to them because many health plans do not make adequate comparable product information available. Moreover, since the introduction of the Medicare HMO option, the long-range plan for management of the Medicare budget has become based on the large-scale voluntary enrollment of beneficiaries into capitated health plans. The policy instrument that has been used to improve beneficiary decisions on how to supplement Medicare coverage is the informational or educational program. This synthesis presents findings regarding the relative effectiveness of different types of health insurance information programs for the Medicare beneficiary in an effort to promote practical use of the most effective types of information.     

Trends in U.S. health insurance coverage, 2001-2003

Against the backdrop of a sluggish economy and rapidly rising health insurance premiums, the proportion of Americans under age 65 covered by employer-sponsored insurance fell dramatically from 67 percent to 63 percent between 2001 and 2003. Although the decline in employer coverage could have spurred a large increase in the uninsured, the proportion of Americans without health insurance did not increase significantly, according to findings from the Center for Studying Health System Change's (HSC) Community Tracking Study Household Survey. Expansion of public health insurance--including Medicaid and the State Children's Health Insurance Program (SCHIP)--forestalled a significant increase in the uninsured, as the proportion of the under-65 population enrolled in public coverage increased from 9 percent to 12 percent.