Comprehensive National Health Insurance Research Articles

Household economic burden of type-2 diabetes and hypertension comorbidity care in urban-poor Ghana: a mixed methods study

BackgroundNon-communicable diseases (NCDs) predispose households to exorbitant healthcare expenditures in health systems where there is no access to effective financial protection for healthcare. This study assessed the economic burden associated with the rising burden of type-2 diabetes (T2D) and hypertension comorbidity management, and its implications for healthcare seeking in urban Accra.MethodsA convergent parallel mixed-methods study design was used. Quantitative sociodemographic and cost data were collected through survey from a random community-based sample of 120 adults aged 25 years and older and living with comorbid T2D and hypertension in Ga Mashie, Accra, Ghana in November and December 2022. The monthly economic cost of T2D and hypertension comorbidity care was estimated using a descriptive cost-of-illness analysis technique from the perspective of patients. Thirteen focus group discussions (FGDs) were conducted among community members with and without comorbid T2D and hypertension. The FGDs were analysed using deductive and inductive thematic approaches. Findings from the survey and qualitative study were integrated in the discussion.ResultsOut of a total of 120 respondents who self-reported comorbid T2D and hypertension, 23 (19.2%) provided complete healthcare cost data. The direct cost of managing T2D and hypertension comorbidity constituted almost 94% of the monthly economic cost of care, and the median direct cost of care was US$19.30 (IQR:10.55–118.88). Almost a quarter of the respondents pay for their healthcare through co-payment and insurance jointly, and 42.9% pay out-of-pocket (OOP). Patients with lower socioeconomic status incurred a higher direct cost burden compared to those in the higher socioeconomic bracket. The implications of the high economic burden resulting from self-funding of healthcare were found from the qualitative study to be: 1) poor access to quality healthcare; (2) poor medication adherence; (3) aggravated direct non-medical and indirect cost; and (4) psychosocial support to help cope with the cost burden.ConclusionThe economic burden associated with healthcare in instances of comorbid T2D and hypertension can significantly impact household budget and cause financial difficulty or impoverishment. Policies targeted at effectively managing NCDs should focus on strengthening a comprehensive and reliable National Health Insurance Scheme coverage for care of chronic conditions.

Metformin in Chemoprevention of Lung Cancer: A Retrospective Population-Based Cohort Study in Lithuania.

Background and Objectives: This study aimed to evaluate the potential chemopreventive effect of antidiabetic medications, specifically metformin and pioglitazone, on lung cancer in patients with type 2 diabetes mellitus (T2DM). Additionally, the potential dose-response relationship for metformin use was analyzed. Methods: We conducted a retrospective cohort study utilizing comprehensive national health insurance and cancer registry databases to gather a large cohort of T2DM patients. Cox proportional hazards regression models were used to assess the risk of lung cancer across different antidiabetic medication groups, adjusting for potential confounders such as age and gender. A dose-response analysis was conducted for metformin users. Results: Our results indicated that metformin users had a significantly lower lung cancer risk than the reference group (HR = 0.69, 95% CI [0.55-0.86], p = 0.001). The risk reduction increased with higher cumulative metformin doses: a metformin cumulative dose between 1,370,000 and 2,976,000 had an HR of 0.61 (95% CI [0.49-0.75], p < 0.001) vs. cumulative metformin dose >2,976,000 which had an HR of 0.35 (95% CI [0.21-0.59], p < 0.001). No significant association between pioglitazone use and the risk of lung cancer was found (HR = 1.00, 95% CI [0.25-4.02]). Conclusions: This study shows that metformin may have a dose-dependent chemopreventive effect against lung cancer in T2DM, while the impact of pioglitazone remains unclear and requires further investigation.

Survival outcomes of primary vs interval cytoreductive surgery for International Federation of Gynecology and Obstetrics stage IV ovarian cancer: a nationwide population-based target trial emulation

The effect of primary cytoreductive surgery versus interval cytoreductive surgery on FIGO IV ovarian cancer outcomes remains uncertain, and may vary depending on the stage and the extraperitoneal metastasis location. Emulating target trials through causal assessment combined with propensity score adjustment has become a leading method for evaluating interventions using observational data. To assess the effect of primary versus interval cytoreductive surgery on progression-free and overall survival in patients with FIGO IV ovarian cancer using target trial emulation. Utilizing the comprehensive French national health insurance database, we emulated a target trial to explore primary versus interval cytoreductive surgery causal impacts on FIGO IV ovarian cancer prognosis (Surgery for Ovarian cancer FIGO 4: SOFI-4). The clone method with inverse probability of censoring weighting was used to adjust for informative censoring and balance baseline characteristics between the groups. Subgroup analyses were conducted based on FIGO stages and extraperitoneal metastasis locations. The study included patients under 75 years of age, in good health condition, diagnosed with FIGO IV ovarian cancer between January 1, 2014, and December 31, 2022. The primary and secondary outcomes were respectively five-year progression-free survival and seven-year overall survival. Among the 2,772 patients included in the study, 948 (34.2%) were classified as FIGO IVA and 1,824 (65.8%) as FIGO IVB at inclusion. Primary cytoreductive surgery was performed on 1,182 patients (42.6%), while interval cytoreductive surgery was conducted on 1,590 patients (57.4%). The median progression survival for primary cytoreductive surgery was 19.7 months (interquartile range [IQR]: 19.3-20.1), compared to 15.7 months (IQR: 15.7-16.1) for those who underwent interval cytoreductive surgery. The median overall survival was 63.1 months [IQR: 61.7-65.4] for primary cytoreductive surgery, in comparison to 55.6 months [IQR: 53.8-56.3] for interval cytoreductive surgery. The findings of our study indicate that primary cytoreductive surgery is associated with a 5.0-month increase in five-year progression-free survival (95% Confidence Intervals [CI]: 3.8-6.2) and a 3.9-month increase in seven-year overall survival (95% CI: 1.9-6.2). These survival benefits of primary over interval cytoreductive surgery were observed in both the FIGO IVA and IVB subgroups. Primary cytoreductive surgery demonstrated improved progression-free survival and overall survival in patients with pleural, supra-diaphragmatic, or extra-abdominal lymph node metastasis. SOFI-4 advocates for the benefits of primary cytoreductive surgery over interval cytoreductive surgery for patients with FIGO IV ovarian cancer, suggesting extraperitoneal metastases like supra-diaphragmatic or extra-abdominal lymph nodes should not automatically preclude primary cytoreductive surgery consideration in suitable patients.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women.

To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis. All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased. Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

PROGRAM UNIVERSAL HEALTH COVERAGE (UHC) DI INDONESIA

Universal Health Coverage (UHC) as a global agreement to provide quality health services for all humans without discrimination with the aim of achieving social inclusion for all community groups is not always smooth in its implementation. This study aims to describe the concept of UHC in Indonesia using the literature review method. The search method was carried out on 2010-2022 articles from several databases such as Google Scholar, PubMed, ProQuest, ScienceDirect, and Researchgate. The results show that Indonesia as a member country of the United Nations is actively involved in developing UHC through the implementation of the National Health Insurance which is supported by the policies of the SJSN Law No. 40/2004 and BPJS Law no. 24/2011. Some of the problems faced by Indonesia in implementing UHC consist of limited equitable infrastructure, lack of availability of health workers spread throughout the country, low participation from the community and other parties in implementation, and the lack of continuous evaluation and monitoring. Four lessons are important for countries wishing to develop comprehensive national social health insurance: Strong political commitment, Comprehensive examination of our health care system, Multistakeholder participation in development, and Continuous monitoring and assessment.

Evaluating the comparative efficiency of medical centers in Taiwan: a dynamic data envelopment analysis application

BackgroundPeople in Taiwan enjoy comprehensive National Health Insurance coverage. However, under the global budget constraint, hospitals encounter enormous challenges. This study was designed to examine Taiwan medical centers' efficiency and factors that influence it.MethodsWe obtained data from open sources of government routine publications and hospitals disclosed by law to the National Health Insurance Administration, Ministry of Health and Welfare, Taiwan. The dynamic data envelopment analysis (DDEA) model was adopted to estimate all medical centers' efficiencies during 2015–2018. Beta regression models were used to model the efficiency level obtained from the DDEA model. We applied an input-oriented approach under both the constant returns-to-scale (CRS) and variable returns-to-scale (VRS) assumptions to estimate efficiency.ResultsThe findings indicated that 68.4% (13 of 19) of medical centers were inefficient according to scale efficiency. The mean efficiency scores of all medical centers during 2015–2018 under the CRS, VRS, and Scale were 0.85, 0.930, and 0.95,respectively. Regression results showed that an increase in the population less than 14 years of age, assets, nurse-patient ratio and bed occupancy rate could increase medical centers' efficiency. The rate of emergency return within 3-day and patient self-pay revenues were associated significantly with reduced hospital efficiency (p < 0.05). The result also showed that the foundation owns medical center has the highest efficiency than other ownership hospitals.ConclusionsThe study results provide information for hospital managers to consider ways they could adjust available resources to achieve high efficiency.

Epidemiological Situation and Medical Management of Gynaecological and Breast Cancers from 1998 to 2018 in West Africa: A Systematic Review

Objective: Gynaecological cancers are public health diseases and contribute to the global burden of diseases. In West Africa most have been carried out on all gynaecological and breast cases to describe the epidemiological features and management modalities.Methods: Our research covered a period from 1998 to 2018. The terms “gynaecological cancers” and “West Africa”; are used to find records in the research databases (PubMed, ScienceDirect, Scopus and Google Scholar). There are countries (Cape Verde, Guinea, Gambia, Liberia, Sierra Leone) in which we have not found any work in the research databases. The process for selecting studies followed selection steps based on PRISMA 2009. Result: Cervical cancer is the commonest, followed by breast cancer, ovarian cancer, uterine or endometrial cancers, vaginal cancer and vulvar cancer. The lowest common was tubal cancers. The two English-speaking countries, Nigeria and Ghana, recorded 60 (60.82%) and 16 (15.68%) articles published respectively. At the same time, these two countries reported the most cases of gynaecological cancers including 72,848 cases (68.97%), 12, 327 cases (11.67%) and 12, 021 cases (11.38%) for Nigeria, Cote d’Ivoire and Ghana respectively. West Africa countries are characterised by poor outcome due to ignorance, superstition, self-denial, late presentation and unavailability of treatment facilities. Conclusion: Our study suggests that comprehensive national health insurance schemes as well as preventive strategies, patient and health work force education may improve the current situation. Also, West African countries must necessarily have a policy of acquiring the technical platforms to carry out these diagnostic and prognostic examinations.

Detecting spatio-temporal hotspots of scarlet fever in Taiwan with spatio-temporal Gi* statistic.

A resurgence of scarlet fever has caused many pediatric infections in East Asia and the United Kingdom. Although scarlet fever in Taiwan has not been a notifiable infectious disease since 2007, the comprehensive national health insurance data can still track its trend. Here, we used data from the open data portal of the Taiwan Centers for Disease Control. The scarlet fever trend was measured by outpatient and hospitalization rates from 2009 to 2017. In order to elucidate the spatio-temporal hotspots, we developed a new method named the spatio-temporal Gi* statistic, and applied Joinpoint regression to compute the annual percentage change (APC). The overall APCs in outpatient and hospitalization were 15.1% (95% CI: 10.3%-20.2%) and 7.7% (95%CI: 4.5% -10.9%). The major two infected groups were children aged 5–9 (outpatient: 0.138 scarlet fever diagnoses per 1,000 visits; inpatient: 2.579 per 1,000 visits) and aged 3–4 (outpatient: 0.084 per 1,000 visits; inpatient: 1.469 per 1,000 visits). We found the counties in eastern Taiwan and offshore counties had the most hotspots in the outpatient setting. In terms of hospitalization, the hotspots mostly occurred in offshore counties close to China. With the help of the spatio-temporal statistic, health workers can set up enhanced laboratory surveillance in those hotspots.

Health care financing and the sustainability of health systems.

The economic crisis brought an unprecedented attention to the issue of health system sustainability in the developed world. The discussion, however, has been mainly limited to “traditional” issues of cost-effectiveness, quality of care, and, lately, patient involvement. Not enough attention has yet been paid to the issue of who pays and, more importantly, to the sustainability of financing. This fundamental concept in the economics of health policy needs to be reconsidered carefully. In a globalized economy, as the share of labor decreases relative to that of capital, wage income is increasingly insufficient to cover the rising cost of care. At the same time, as the cost of Social Health Insurance through employment contributions rises with medical costs, it imperils the competitiveness of the economy. These reasons explain why spreading health care cost to all factors of production through comprehensive National Health Insurance financed by progressive taxation of income from all sources, instead of employer-employee contributions, protects health system objectives, especially during economic recessions, and ensures health system sustainability.

Medical utilization by liver cancer patients under the National Health Insurance program in Taiwan: A population-based cross-sectional study

Aims Taiwan implemented a comprehensive and universal National Health Insurance (NHI) program to cover all inhabitants. This study aimed to assess the medical utilization by liver cancer patients under the NHI. Methods This retrospective cross-sectional study used a sampled NHI research database, which contained 1 million beneficiaries. The claims of liver cancer patients in 2009 were analyzed. The other beneficiaries without liver cancer who used medical services in 2009 served as the control patients. Results Among the 2335 identified liver cancer patients, 2178 (93.3%) patients used outpatient services and 1193 (51.1%) patients used inpatient services. Liver cancer accounted for 1.8% of the NHI's total cost. The cost per visit was United States dollars (US$)59.30 for outpatient care and US$2070.30 for inpatient care. The annual cost per patient was US$4746.60; US$1951.00 were for outpatient care and US$2795.60 for inpatient care. Patients who were female, in their 60s, had a lower income, and lived in southern Taiwan had a higher cost per patient (p < 0.0001). Fees for consultation, treatment, and medical supplies (57.3%) accounted for the highest portion of outpatient costs, followed by drug fees (30.0%) and diagnosis fees (11.2%). Ward fees accounted for the highest portion of inpatient costs (19.0%), followed by drug fees (18.7%) and X-ray fees (14.9%). Private hospitals were visited more frequently than public hospitals. The cost per visit and cost per patient with liver cancer were 206.0% and 666.8%, respectively, of the cost of the control patients. Conclusion The cost of liver cancer care is substantial and varies by sex, age, income, and geographic distribution. It is critical to reduce the incidence of liver cancer and identify cost-effective treatment strategies.

Medical Device Reimbursement Coverage and Pricing Rules in Korea: Current Practice and Issues with Access to Innovation

The development of health funding policy in Korea has followed the country’s rapid economic development, with a comprehensive National Health Insurance (NHI) system in place by 1989. The funding of medical devices has followed this progression, with incorporation into the NHI reimbursement system in 2000 (several years later than pharmaceuticals), but important issues affecting patient access remain. Although the effect of devices on the NHI budget is relatively modest (only about 4%), because of concerns about NHI sustainability, attention has increasingly been paid to their management and funding. Unlike pharmaceuticals, however, it has been quite challenging to develop clear and fair criteria for reimbursement coverage and pricing of medical devices. The two key and longstanding issues around the reimbursement of medical devices in Korea are how to expedite market entry of improved or innovative medical devices at appropriate prices, and how to satisfactorily lower the reimbursement levels of older devices, thereby making headroom for new technologies to be reimbursed. Despite protracted discussions over the last decade, industry and government have been unable to reach full agreement. There has been some progress (e.g., introduction of the Value Appraisal and the Revaluation Systems), but there remains urgent need for productive discussion and consensus between government and industry regarding reasonable funding rules, transparency, and clarity in the reimbursement pricing process for medical devices.

Gender differences in emergency stroke care and hospital outcome in acute ischemic stroke: a multicenter observational study

BackgroundWe aimed to investigate the effect of gender difference on the accessibility to emergency care, hospital mortality and disability in acute stroke care. MethodsThis study was performed on a single-tiered basic emergency medical service with a comprehensive national health insurance. Demographic variables, risk factors, elapsed time intervals, performing diagnosis and treatment options, hospital mortality, and modified Rankin Scale of acute ischemic stroke during 2008 were collected. We modeled the multivariate regression analysis for gender differences on the accessibility, hospital mortality, and disability. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated adjusting for potential risk factors. ResultsThe total number of patients was 6635. The time from symptom onset to emergency department (ED) arrival and to computed tomography or magnetic resonance imaging scan and from ED arrival to computed tomography or magnetic resonance imaging scan was significantly longer in women. No significant difference was found in either the time to intravenous thrombolysis or in the number of patients who received intravenous thrombolysis, anti-platelet therapy, anti-coagulation, or operation. The hospital mortality rate was higher in women (3.9%) than in men (2.9%) (P = .03). The increased disability was significantly higher in women (67.8%) than in men (65.1%) (P = .02). The hospital mortality and increased disability showed a non-significant difference between the 2 genders in the adjusted model (OR, 1.10; 95% CI, 0.74-1.64) and (OR, 1.11; 95% CI, 0.96-1.28), respectively. ConclusionThe adjusted model for risk factors showed no significant difference on hospital mortality and disability between the 2 genders for stroke patients.

The double-edged sword: financial source of household healthcare expenditure in Ghana

In many regions, some of the most formidable enemies of health are joining forces with the allies of poverty to impose a double burden of disease, disability and premature death. This paper looks at the main financial sources households use to finance healthcare in Ghana. It examines the spatial and socio-economic dynamics and the challenges these pose to health and development. Analysis of the 2003 Ghana World Health Survey data indicates that approximately 41% of households depend on more than one financial source with 88% depending on household income to finance healthcare expenditure. The high dependency on household income will erode gains in the economic and health sector in the midst of the recent global economic recession. Comprehensive national health insurance programs that cover emerging disease conditions will mitigate the double burden of disease on households in emerging economies.

A profile analysis of some selected health risk indicators in South African women (30 -65 years)

The objective of this study was to compile a profile of some selected health risk indicators (hypertension, hypercholesterolemia, obesity, smoking and physical inactivity) of South African women, aged 30-65 years ( x = 41.6 ± 12.8 years) which can be influenced by lifestyle. Therespondents comprised 3 818 women who were members of a comprehensive national health insurance in South Africa. Data were collected by means of a demographic questionnaire (including smoking habits), a physical activity questionnaire as well as field tests assessing nonfasting total cholesterol, blood pressure and obesity (BMI). The respondents were selected in two age groups (≤ 49 and ≥ 50 year) primarily representing the pre and postmenopausal life stages of women. From the descriptive data it appears that the younger group (≤ 49) tends to be physically less active than the older group (≥ 50). In all the other parameters the older group revealed higher mean values. However, none of these differences are of practical significance. When a profile is constructed, results indicate that a higher percentage of the younger group fall into the poor category suggesting a more destructive lifestyle in this category. The only exception is smoking where the older group indicated that 5.2% and 9.3% are in the poor and moderate category in comparison with the 2.4% and 11.5% of the younger group respectively.

The Rise and Fall of HMOs: An American Health Care Revolution (review)

Reviewed by: The Rise and Fall of HMOs: An American Health Care Revolution Daniel M. Fox Jan Gregoire Coombs . The Rise and Fall of HMOs: An American Health Care Revolution. Madison: University of Wisconsin Press, 2005. xviii + 412 pp. $35.00 (0-299-20240-2). Jan Coombs has written two books under a single title. One is a history of the Marshfield Clinic, a large medical group practice that became a pioneering rural Health Maintenance Organization (HMO) in response to incentives offered by the federal government since the 1970s; the other is a history of health-care policy in the United States during the past seventy years, and especially the last three decades. Coombs's history of the Marshfield Clinic contributes to the interdisciplinary literature on the history and operations of health-care organizations. Using archival sources and information from interviews that she conducted, she describes the effects on the clinic of competing opinions concerning the organization and delivery of health services, of the goals and management style of key individuals, and of federal and state policy. Her general history of health policy is less successful. She has read widely in recent history, but she uses these sources to justify her opinions about how Americans ought to behave, and on public officials. She berates Americans—apparently all of us—for tolerating a "misguided, wasteful system that leaves so many disadvantaged Americans groveling for scrapes [sic] of care" (p. 291). Moreover, government is incompetent to address "health care problems" because "public programs operate at cross-purposes from one another, protected by administrators intent on guarding their own turf" (pp. 74–75). These broad and controversial opinions seem out of place in a book that an author and a university press put forward as meeting the standards of scholarship. The author occasionally blames health-care organizations for operating within constraints over which they actually had no control. For instance, she writes that "most HMOs failed the social test of accessibility in the 1970s because they marketed policies only to employee groups" (p. 125). Two paragraphs later, however, she admits that few people who were not members of groups could afford to purchase coverage from HMOs, "even though prepaid plans were often less costly than traditional insurance policies" (p. 125). Some of Coombs's facts are wrong. She writes that in 1934 Franklin D. Roosevelt "asked Isidore Falk and Edgar Sydenstricker to help him draft" the health insurance provisions of what became the Social Security Act (p. 5). According to several historians, however, Roosevelt had decided to omit health insurance from Social Security; a senior official who hoped to persuade the president to change his mind asked a foundation to send two employees, Falk and Sydenstricker, to help the committee that was drafting the report that preceded the Social Security Act. Coombs also claims, contrary to the literature, that Congress seriously considered legislation for comprehensive national health insurance in 1968 (p. 14). A final example: she says that "self-insured plans were more expensive than purchased [that is, commercial and risk-based] policies" (p. 137)—a statement [End Page 607] that would surprise decision makers in firms that employ the majority of Americans who have health benefits. Daniel M. Fox Milbank Memorial Fund Copyright © 2006 The Johns Hopkins University Press

Medical Bankruptcy: Myth Versus Fact

David Himmelstein and colleagues recently contended that medical problems contribute to 54.5 percent of personal bankruptcies and threaten the solvency of solidly middle-class Americans. They propose comprehensive national health insurance as a solution. A reexamination of their data suggests that medical bills are a contributing factor in just 17 percent of personal bankruptcies and that those affected tend to have incomes closer to poverty level than to middle class. Moreover, for national health insurance to have an impact, it would have to define "medical" expenses in a much broader way than is now typical of either private or government-funded plans.

Dentistry in Taiwan, Republic of China: national health insurance reforms, illegal dentistry and plans for peer review quality control

The dental health care system in Taiwan, Republic of China is described in terms of demographics, structure, context of treatment and historical development of the dental health care payment system. A notable characteristic of the system is the existence of trade dentists, who operate without licensure. Their popularity and price advantage has maintained a political base that affects policy decisions. Health care reforms of March, 1995 with a comprehensive national health insurance, as well as ambitious plans for systematic peer review quality control of dentists' work are unique health care developments worthy of the attention of health care policy makers in other countries who are studying health care reform processes.

Health care reform in Israel: An historical and sociopolitical conundrum

A new and comprehensive National Health Insurance Law was implemented in Israel on January 1, 1995. This major health care reform initiative culminated an effort lasting several decades to assure broad universal health care coverage for the population as a matter of national law. Issues that affected the development of the reform package included 1) the formation of sick funds that provide care to over 96% of the population as part of other powerful sociopolitical organizations, 2) the historical development of parallel private July 16, 1995 and governmental health care systems before Israel became a state in 1948 and the post-state maintenance of multiple health care delivery systems, and 3) the close interactions of health care systems and the political processes and parties of the nation. This paper describes the effects of these forces on resisting changes that were widely accepted as being necessary to expand access, control rising health care costs, and improve the efficiency of the nation's health care system.

It's the institutions, stupid! Why comprehensive national health insurance always fails in America.

We argue that the United States does not have comprehensive national health insurance (NHI) because American political institutions are biased against this type of reform. The original design of a fragmented and federated national political system serving an increasingly large and diverse polity has been further fragmented by a series of political reforms beginning with the Progressive era and culminating with the congressional reforms of the mid-1970s. This institutional structure yields enormous power to intransigent interest groups and thus makes efforts by progressive reformers such as President Clinton (and previous reform-minded presidents before him) to mount a successful NHI campaign impossible. We show how this institutional structure has shaped political strategies and political outcomes related to NHI since Franklin D. Roosevelt. Finally, we argue that this institutional structure contributes to the antigovernment attitudes so often observed among Americans.

State health insurance initiatives: what the literature is telling us.

The absence in the United States of a comprehensive national health insurance system has left a significant number of people either without coverage or with only partial (and inadequate) coverage. Individual states have sought to remedy this through a number of initiatives, but the majority have been incremental in nature, not universal. Sifting through the extensive literature on what states are doing and have been doing, the author reveals the nature of their attempts (and their infrequent successes) and provides issues and questions that must be dealt with before a system acceptable--and accessible--to all can be achieved.