Costs For Everyone Research Articles

Medical crowdfunding in a healthcare system with universal coverage: an exploratory study

BackgroundIn recent years, crowdfunding for medical expenses has gained popularity, especially in countries without universal health coverage. Nevertheless, universal coverage does not imply covering all medical costs for everyone. In countries with universal coverage unmet health care needs typically emerge due to financial reasons: the inability to pay the patient co-payments, and additional and experimental therapies not financed by the health insurance fund. This study aims at mapping unmet health care needs manifested in medical crowdfunding campaigns in a country with universal health coverage.MethodsIn this exploratory study we assess unmet health care needs in Germany by investigating 380 medical crowdfunding campaigns launched on Leetchi.com. We combine manual data extraction with text mining tools to identify the most common conditions, diseases and disorders which prompted individuals to launch medical crowdfunding campaigns in Germany. We also assess the type and size of health-related expenses that individuals aim to finance from donations.ResultsWe find that several conditions frequently listed in crowdfunding campaigns overlap with the most disabling conditions: cancer, mental disorders, musculoskeletal disorders, and neurological disorders. Nevertheless, there is no strong association between the disease burden and the condition which prompted individuals to ask for donations. Although oral health, lipoedema, and genetic disorders and rare diseases are not listed among leading causes of disability worldwide, these conditions frequently prompted individuals to turn to crowdfunding. Unmet needs are the highest for various therapies not financed by the health insurance fund; additional, complementary, and animal-assisted therapies are high on the wish list. Numerous people sought funds to cover the cost of scientifically poorly supported or unsupported therapies. In line with the social drift hypothesis, disability and bad health status being associated with poor socioeconomic status, affected individuals frequently collected donations for their living expenses.ConclusionsIn universal healthcare systems, medical crowdfunding is a viable option to finance alternative, complementary, experimental and scientifically poorly supported therapies not financed by the health insurance fund. Further analysis of the most common diseases and disorders listed in crowdfunding campaigns might provide guidance for national health insurance funds in extending their list of funded medical interventions. The fact of numerous individuals launching crowdfunding campaigns with the same diseases and disorders signals high unmet needs for available but not yet financed treatment. One prominent example of such treatment is liposuction for patients suffering from lipoedema; these treatments were frequently listed in crowdfunding campaigns and might soon be available for patients at the expense of statutory health insurance in Germany.

Cost Caps and Coverage for All: How to Make Health Care Universally Affordable

Cost Caps and Coverage for All is a comprehensive approach to health care. It protects everyone through two main parts: 1) Cost Caps: Caps premiums, deductibles, and other out-of-pocket costs for everyone based on income: 2) Universal Coverage: Ensures health care is a basic human right by automatically covering everyone not currently insured in an affordable plan. It would be paid for by protecting patients against high prices, realigning incentives to deliver better value for patients, reducing complexity for patients, and targeted tax increases on the wealthy.

Differences Between Younger and Older US Adults With Multiple Chronic Conditions.

IntroductionAdults with multiple (≥2) chronic conditions (MCCs) account for a large portion of US health care costs. Despite the increase in MCC rates with age, most people with MCCs are working age. The study objective was to compare adults with MCCs who were younger than 65 years with those aged 65 years or older on selected measures to better understand the differences between groups and inform interventions that could lower health care costs.MethodsData from respondents to the 2015 Behavioral Risk Factor Surveillance System data (N = 201,711) were used to compare adults aged 65 or older with MCCs with those younger than 65 with MCCs in unadjusted and adjusted analyses on chronic conditions, quality of life measures, disability status, access to health care, and modifiable risk factors. MCCs were based on up to 12 chronic conditions (heart disease, stroke, asthma, arthritis, chronic obstructive pulmonary disease, high cholesterol, cognitive impairment, diabetes, depression, chronic kidney disease, cancer other than skin, and hypertension).ResultsConsistent with 80% of all adults being younger than 65, more than 60% of adults with MCCs were younger than 65 years. Compared with adults aged 65 or older with MCCs, those younger than 65 were more likely to report asthma, cognitive impairment, depression, smoking, obesity, poorer access to health care, disability, and worse quality of life in both unadjusted and adjusted analysis.ConclusionTo decrease the burden of chronic diseases, adults younger than 65 with MCCs should get the treatment they need to reduce the chance of developing more chronic conditions as they age. The ultimate goal is to improve health status and reduce health care costs for everyone with MCCs.

Getting There from Here: 30 in 2020 in the Democratic Republic of Congo

Internet penetration in the Democratic Republic of Congo (DRC) is 4%. According to radio okapi, the high costs of services and the lack of infrastructure block most people from accessing the Internet. The high Internet costs are due to the high cost of satellite bandwidth use, which raises Internet providers operating costs. Low Internet penetration in the D.R.C. is a brake on the development of this country, experts in the sector confirm. This damages both the economy and society, and is especially dangerous in case of emergency. The objective of the Interagency Task Force and Advisory Group is to support the D.R.C. achieving 30% penetration as soon as 2020. This paper assesses an Interagency Task Force and Advisory Group (IATAG) helping catalyze interagency and civil society cooperation with industry investment to enable D.R.C. Internet penetration to exceed 30% in 2020. If successful, the economic and social benefits are obvious as a more connected and wealthier D.R.C. creates more economic opportunities for citizens and investors, improves health and well-being, and improves the functioning of the public sector. Fieldwork to identify key inhibitors and barriers, which must be removed or reformed if the DRC Broadband Vision is to be realized, is among the research methods to be used in this paper. Experiments with government ministries, governors, civil society actors, and firms will be evaluated. Sociopolitical challenges will vary both between and within the Provinces of the Democratic Republic of Congo. To obtain a realistic view of current conditions and critical barriers, infrastructure providers of telecommunications and energy, and their business, residential and public sector customers must be encouraged to contribute, along with potential new market entrants. Investors and industry partners, who affirm they would contribute if identified barriers were removed, are participating in this multi-stakeholder process. The conclusions of this paper may have significant application to realizing efforts of international agencies and the technology industry to facilitate the next billion and half people accessing the Internet. Already, the nascent efforts in the DRC are being attracting growing interest in several other African nations whose geography, economy, and political instability may also have left large numbers of people excluded from Internet access to date. Are there lessons to be learned from the DRC on what policy approaches and technology innovations may help rural areas, education and emergency services leap ahead? Aggregating demand by supporting inter-city hybrid heterogeneous (fiber, wireless, and satellite, as well as off-grid solutions) networks will be key to enabling sustainable, rapid growth in connectivity and Internet access, this research indicates. Establishment of an annual series of DRC Internet Forum meetings, to facilitate continuous multistakeholder dialogue is planned. Several Provinces whose Governors and citizens may be prepared to commit to supporting the Vision will prove their commitment by formally volunteering their Provinces as Innovation Zones. Both government and civil society clearly must be prepared to take practical, and difficult, actions to make the plan implementable, and change possible. The IATAG is developing a checklist and brief questionnaire for submission by the Governor of interested Provinces, with indications of broad support by local officials, university and school leaders, businesses, and community organizations. Results of this questionnaire may be shared with TPRC participants for their feedback and suggestions. Incumbent telecommunications operators identifying what they perceive to be the key challenges in the region is also critical input for the Task Force to consider. For example, it may be that mobile backhaul is the top obstacle, as it was in Ugandan regions where Facebook co-invested in 2017 with two operators to remove that barrier. This paper will also report on findings from the point of view of incumbent and new entrant operators. The virtuous circle of private sector actors encouraged by reformed government innovation policies and engaged community groups inviting change, will risk investment in advanced wireless, mobile and fiber infrastructure in the DRC as soon as possible. This can increase access and can lower costs for everyone while improving quality and variety of services far beyond 4G. These include innovative hybrid heterogeneous software-defined and virtualized networks offering cloud services across wireless grids for the Internet of Things with edgeware.

Private and Social Incentives for Vertical Contract Disclosure

We follow the framework in Arya and Mittendorf's 2011 Rand Journal of Economics paper but extend their analysis by investigating supplier(s)' equilibrium choices of disclosure or confidentiality regarding their contract terms with the downstream retailers. In the case of a common supplier, we find that the unique subgame perfect Nash equilibrium (SPNE) is for the supplier to choose disclosure. This private incentive is opposite to social incentive, which calls for the regulator to choose confidentiality. In the case of dedicated suppliers, however, there are multiple SPNE due to coordination issues between the suppliers. The case which maximizes social surplus – disclosure – can be supported as a SPNE, together with the case of confidentiality, which maximizes supplier profits at the cost of everyone else. Copyright © 2014 John Wiley & Sons, Ltd.

Private and Social Incentives for Vertical Contract Disclosure

We follow the framework in Arya and Mittendorf (2011) but extend their analysis by investigating supplier(s)' equilibrium choices of disclosure or confidentiality regarding their contract terms with the downstream retailers. In the case of a common supplier, we find that the unique SPNE is for the supplier to choose disclosure. This private incentive is opposite to social incentive which calls for the regulator to choose confidentiality. In the case of dedicated suppliers, however, there are multiple SPNE due to coordination issues between the suppliers. The case which maximizes social surplus -- disclosure -- can be supported as a SPNE, together with the case of confidentiality which maximizes supplier profits at the cost of everyone else.

Reproductive costs for everyone: How female loads impact human mobility strategies

While mobility strategies are considered important in understanding selection pressures on individuals, testing hypotheses of such strategies requires high resolution datasets, particularly at intersections between morphology, ecology and energetics. Here we present data on interactions between morphology and energetics in regards to the cost of walking for reproductive women and place these data into a specific ecological context of time and heat load. Frontal loads (up to 16% of body mass), as during pregnancy and child-carrying, significantly slow the optimal and preferred walking speed of women, significantly increase cost at the optimal speed, and make it significantly more costly for women to walk with other people. We further show for the first time significant changes in the curvature in the Cost of Transport curve for human walking, as driven by frontal loads. The impact of these frontal loads on females, and the populations to which they belong, would have been magnified by time constraints due to seasonal changes in day length at high latitudes and thermoregulatory limitations at low latitudes. However, wider pelves increase both stride length and speed flexibility, providing a morphological offset for load-related costs. Longer lower limbs also increase stride length. Observed differences between preferred and energetically optimal speeds with frontal loading suggest that speed choices of women carrying reproductive loads might be particularly sensitive to changes in heat load. Our findings show that female reproductive costs, particularly those related to locomotion, would have meaningfully shaped the mobility strategies of the hominin lineage, as well as modern foraging populations.

An Expenditure Saved Is an Expenditure Earned: Fanny Fern's Humoring of the Capitalist Ethos

Among the many ridiculous characters in Fanny Fern's Ruth Hall: A Domestic Tale of the Present Time, the heroine's mother-in-law, Mrs. Hall, stands out as the most comical with her supply of unhelpful cliches and suggestions. One of her sayings in particular, Waste want not, taken from Benjamin Franklin, sums up her role as one of the many spokespeople for economy in Ruth Hall (31). In this role, she complains that her new daughter-in-law's frilly underwear and silk stockings reveal a profound disregard for economy, and even suggests that Ruth apply something to straighten her curls because one should avoid everything that looks frivolous (30-31). Her husband, Dr. Hall, counts the pieces of firewood the servant uses each night and spends his dinner hour [narrating] the market prices he paid for each article of food upon the table (36, 38). Dr. and Mrs. Hall betray a trait common in the novel's abundant stereotypical characters: Although they stand in the privileged position to spend, they compulsively save at the cost of everyone around them. During the brief phase in the novel when the heroine, Ruth, is married and financially supported, these characters serve as comical nuisances that cause familial tension; however, when Ruth's husband dies and leaves her penniless, these characters threaten to deprive the widow and her children of their basic necessities. The satirized stereotypes of Ruth Hall are powerful figures who blame Ruth's financial hardships and their refusal to help her on her lack of economy. Old Mrs. Hall's Waste want not becomes a motto through which the empowered attribute poverty to sufferers' thriftlessness and thereby absolve themselves of responsibility (87). In contradistinction to these cliched characters with their secure cultural positions, Ruth Hall must make her own way through nineteenth-century industrial capitalism. The novel's title pays tribute to her singularity amid the generic masses. As ambassadors of acquisition and conservation, old Mrs. Hall and her fellow economizers are finally laughed off once Ruth learns how to negotiate the financial world herself. Ruth Hall's heroine-turned-capitalist negotiates a comfortable position for herself and her daughters. Even as the novel resolves economic injustices thematically, its techniques of humor express the cultural pressures that these now-marginalized characters represent--namely, the pressure to save time and energy. (1) Drawing on Sigmund Freud's The Joke and Its Relation to the Unconscious, trace how Ruth Hall's comical stereotypes and wordplay enable readers to save the exertion required to understand new characters or ideas, to pursue a chain of reasoning, or to feel a certain way. However, rather than helping the reader accrue and conserve capital--the motivation for saving that the elder Halls and the novel's plot resolution ultimately endorse--the savings of the comical are expended in laughter. Through this process, Fern renders the comic a space of resistance by way of its overt, nonproductive consumption of energy. This technique aligns the novel's comical episodes with its sentimental passages: Both modes of writing solicit audience expenditures, one in the form of laughter and the other in the form of affect. Paving the way for the techniques of the comic, Ruth Hall's preface justifies formal choices through a socioeconomic concern for efficiency. Fern writes: I have compressed into one volume what might have expanded into two or three. have avoided long introductions and descriptions, and have entered unceremoniously and unannounced, into people's houses, without stopping to ring the bell (iii). Thus, even before introducing characters who enforce thriftiness, Fern reveals that saving time and space motivates the narrative. With chapters that are often the length of newspaper sketches--the form through which the heroine will build her own capital--the narrative frequently lets the information exchanged in conversation drive the plot forward without reiteration or explanation. …

Human papillomavirus vaccination uptake and factors related to uptake in a traditional desert city in the United Arab Emirates

It is important to assess uptake of a new vaccine. The present survey estimated the uptake of the recently introduced human papillomavirus vaccine (HPVV) in the emirate of Abu Dhabi and also explored barriers to uptake. A questionnaire survey was conducted in secondary schools, enrolling 334 girls. The uptake percentage was estimated and factors associated with uptake were assessed with multilevel logistic regression. Crude vaccination uptake was 53%. Factors positively associated with uptake were, among others, having knowledge on human papillomavirus (vaccine) and having United Arab Emirates (UAE) nationality. The HPVV uptake of just over 50% could probably be improved by educating the target group and their parents before offering the HPVV and by making it free of costs for everyone.

Rights and Responsibilities in Health Care

IN MANY STATES, TEENAGERS CAN APPLY FOR A DRIVER’S license when they are 16 years old. To obtain the license, they need to pass a written examination, perform adequately on a driving test, and demonstrate that they have insurance. But all drivers can do things to lose their license. For example, the law requires that drivers stop at red lights, even in the middle of the night when the street is empty. If drivers choose to ignore this law, they risk being ticketed; enough tickets will probably cost them the right to drive. These requirements are not arbitrary; they were developed to preserve life and reduce the cost of everyone’s insurance. When young adults are 26 years old, they can no longer be covered under their parents’ health insurance plan. However, they have other coverage options. If they work, and their employer offers insurance, they need only check a box. If they apply for an individual policy, they may need to prove that they do not have preexisting conditions and will need to provide extensive background information. But in either case, they do not need to know about the health care system or how to use it efficiently and appropriately. Misuse of the system may cost them a monetary penalty, but for these young adults, those penalties will seem far less important compared with the loss of their license to drive. What if this approach to health insurance changed? What if to obtain and keep health insurance, individuals had to pass something like a driver’s license test? What should they study to prepare for the test? What should be taught? What skills should be demonstrated? Should insurance be more costly, or even withdrawn, not because individuals become sick but because they do not use preventive services or evidence-based care in a manner that both protects their health and reduces health care costs for others? If society both provides health insurance and helps those who do not have the ability to use services effectively, what kind of penalty for misuse would be ethically and morally acceptable? Should penalties and rewards be applied first to the middle class, as opposed to disadvantaged individuals who are enrolled in Medicaid? Over the last 40 years, tests and drugs have been developed that can predict or change the course of illness—even a potentially silent condition such as hypertension. The medical profession has responded to these changes by teaching physicians skills for motivating patients to obtain necessary diagnostic tests, take necessary medications, be vaccinated, and receive routine preventive services. However, physicians have not had remarkable success in improving adherence to necessary interventions, such as those for hypertension, or in containing the costs of providing care. Is it time to admit that unless patients assume greater responsibility, these problems will not be solved? For instance, consider a health system in which individuals who have health insurance and are competent to care for themselves would be required to take medications and have procedures known to be necessary and would do so; and a severe penalty would be imposed if they do not. What if individuals were required to receive vaccines for which they were eligible, as soon as the vaccines became available— and were penalized if they contracted an illness the vaccination could have prevented? What if individuals with hypertension or hyperlipidemia who did not take their medications became responsible for some of the costs of future cardiac care? If the nation’s future health system is expected to contain costs and improve value, shouldn’t the recipients be expected to be true partners in achieving those goals? This kind of sea change would take time to implement, would need to be preceded by education, and should be first implemented among individuals for whom language or competence would not be a barrier to getting required care. This policy would also need to focus on medications and procedures for which effectiveness has been well established. Blue ribbons and awards are given to health plans for having high mammogram rates, high colonoscopy rates, and appropriate levels of hemoglobin A1c and low-density lipoprotein cholesterol among their members. Perhaps the awards should be given to patients instead of physicians and health organizations. Perhaps it is time to say to the American public: “Certain procedures, medications, and preventive care will make a difference in your health, and it is your responsibility, not your physician’s, to take or to do them.” If individuals want to use their car warranty to get repairs, they have to show that they have provided at

How Many Physicians Are Enough?

Like the health economics professor that he is, Richard Scheffler takes readers of his most recent book into a virtual classroom, offers up an analysis of how many doctors are enough, and spices the mix with the opinions of respected peers. But, ultimately, he provides no definitive opinion on the question that begs for an answer: how many physicians would be an adequate number to care for a more demanding baby-boom generation, to cope with an explosion of chronic illness, and to prepare for a population that is growing at the rate of about twenty-five million people every decade? Although Scheffler offers different takes on the contentious issues surrounding physician supply, he is reluctant to offer a definitive view on the appropriate number. As he notes, previous analyses have declared with confidence that the United States faces a surplus (or a shortage) of physicians given societal trends at the time. Most (if not all) of the predictions have been proved wrong, and accurately forecasting the right number remains one of the many challenges facing our troubled health care system. Vast differences of opinion continue to provide grist for the continuing debate.1 Scheffler does state a preference to err on the side of too many rather than too few doctors and to modestly increase the number of primary care physicians. But in his final chapter he says, “Forecasting efforts in the past have missed the mark and even led to strategies that caused problems over the long term. Therefore, as a health economist, my inclination is to summarize the input on all sides and leave it at that” (p. 191). (Of the twenty-seven health policy experts he interviewed, most who addressed the question of whether more doctors should be trained opposed an increase in physician supply or offered cautionary comments.) Scheffler’s book is a useful addition to the literature because he probes the extensive relationship between the market and physician supply in an interesting way. His conclusion is that the market indicators—including physician income, selection of specialty, geographic distribution of doctors, and numbers of nonphysician clinicians in the workforce—all respond rapidly and predictably to economic incentives in the marketplace. Morever, he says, the connection between the market and these indicators was tighter during the heyday of managed care than before. Scheffler intends for his book to help policymakers and other interested parties better visualize the economic framework that underlies health care delivery and the supply of physicians. He dwells on the role managed care in redistributing market power between physicians and health insurers. He writes: “The incentives that were applied under managed care were intended to diminish the moral hazard that encouraged excessive services in the fee-for-service environment and resulted in fast-increasing costs for everyone.” As a consequence, physicians “saw their professional autonomy, their income, and their economic power greatly reduced. Market power shifted to payers and away from doctors” (p. 19). B o o k R e v i e w s

A Scalable Wireless Body Area Network for Bio-Telemetry

In this paper, we propose a framework for the real-time monitoring of wireless biosensors. This is a scalable platform that requires minimum human interaction during set-up and monitoring. Its main components include a biosensor, a smart gateway to automatically set up the body area network, a mechanism for delivering data to an Internet monitoring server, and automatic data collection, profiling and feature extraction from bio-potentials. Such a system could increase the quality of life and significantly lower healthcare costs for everyone in general, and for the elderly and those with disabilities in particular.

Thinking Clearly About the Issue of Health Insurance

again, issues of health insurance are figuring prominently in a presidential election campaign, with the candidates' proposals subject to microscopic dissection in the popular and trade press alike. The problems those proposals purport to address the growing number of Americans without health insurance, whose access to health services is thus significantly compromised; growing out-of-pocket costs for increasing proportions of those who are nominally insured in a time of stagnant real incomes and growing expenses for food, housing, and fuel; increased costs for everyone are surely serious enough, and deserving of political attention and, more importantly, of policy action. Many of those specific problems are discussed with creativity and insight in the articles that make up the bulk of this Special Theme Issue of Medical Care. But the broader issues underlying the political debate, and even the likelihood of effective action by a new administration to address these issues, are increasingly obscured by confusion as to what health insurance is, and should be, all about. We run a serious risk of solving the health insurance problem without adequately addressing the problems health insurance was invented to address, while leaving much of the population with compromised or inadequate access to the health care they need.

The Effect of Health Insurance Disparities on the Health Care System

Uninsured patients put a strain on the health care system that ultimately results in increased health care costs for everyone. The challenges faced by the Harris County Hospital District in Houston, TX, as a result of an increasing number of uninsured and underinsured patients include overcrowding in its health care facilities, decreased reimbursement from government programs, and patients who postpone seeking medical treatment until their situation is emergent and whose care is therefore more expensive. Strategies for addressing these problems may include instituting an "everybody pays" program, improving access to care for the uninsured, and reducing or eliminating unnecessary services.

Does society benefit from investor overconfidence in the ability of financial market experts?

This paper develops a securities market model in which participants’ beliefs diverge and prices are monotonic in beliefs. Relative to rational expectations (i.e., correct and unanimous beliefs), overconfidence among uninformed traders about the precision of experts’ information leads to Pareto-superior equilibria. Efficiency-enhancing departures from rational expectations occur over a dense subset of parameter space, but only for one configuration of beliefs: uninformed traders must be more confident than informed experts. Overconfidence in the form of excessive trust in the predictive ability of experts sets off a virtuous cycle of increased trading that improves liquidity and reduces transaction costs for everyone.

From the Guest Editor for the Special Issue on Computational Molecular Biology/Bioinformatics

W are in a revolution. The Human Genome Project brought biology from an informationpoor to an information-rich science, and this has caused a permanent change in its research, with causal effects on medical research. In fact, it will not be long before the general public realizes the revolution. Just as two decades ago, most people did not know about computers, so they do not know about micro-array chips, DNA, and the genome. We shall move from health care that is diagnostic and remedial to a system that is predictive and preventive. Each of us will have our DNA on a chip, and a doctor will be able to predict some of what will be wrong and right with each of us in the near and far future. Predicting diseases will enable early therapeutics. It is reasonable to expect that such personalized medicine will enable more drugs to come to market, reducing pharmaceutical costs for everyone. We in operations research have a great opportunity to be a part of this revolution because of what we do—we take an interdisciplinary approach to problemsolving. Our strengths are modeling, analysis, and algorithm design. We provide a quantitative foundation for a broad spectrum of problems, and we can see transfers of technologies because of our abilities to bridge the concrete with the abstract. This issue of the INFORMS Journal on Computing is testimony to that, and it is only the beginning. I began this project with the intention of attracting others in OR to join in this great adventure, and these papers have helped me fulfill this goal with the diligence of our Editorial Board:

An Equality Paradigm for Preventing Genetic Discrimination

In this article we argue for the creation of an equality-based protection similar to that of race and sex discrimination. In doing so, we demonstrate the confluence of genetic discrimination with that of disability discrimination, and discuss some problems inherent with current approaches to statutory protection in both these areas. We show that the ADA, as well as current and proposed genetic discrimination laws, bifurcates the population into protected and unprotected groups. The ADA and specialized genetic discrimination law protect different groups that are, essentially, mirror images of each other while leaving an important part of the population unprotected. In practice the ADA applies only to those individuals who are seriously symptomatic, while genetic discrimination law extends only to those who are either nonsymptomatic or asymptomatic. Falling between these two poles and thus lacking protection is a large group of presymptomatic individuals with genetic anomalies which may never be expressed or, if expressed, may not manifest as unmitigatable functional impairments. Because excluding this latter category of individuals from labor market participation (and attendant social opportunities) is probabilistically unjustifiable as well as enormously costly to society, we advocate their inclusion in the classification of the group targeted for genetic discrimination protection. We also set to rest fears that so broadly extending protection will increase transactional costs for everyone. In making these assertions, this article diverges widely from existing legal scholarship. To date, commentators advocate either for greater application of the ADA or the enactment of specific legislation to the realm of genetic discrimination without either noting or addressing the exclusion from coverage of presymptomatic individuals.

Ensuring access to health care: the Bush plan.

IBELIEVE THAT ALL AMERICANS SHOULD HAVE ACCESS TO affordable, high-quality health care. Rising health care costs impose a burden on families and small businesses and put coverage out of the reach of many Americans. My plan will help reduce the rising cost of health care, provide new and affordable health coverage options for all Americans, and provide not just a government program but a path to greater opportunity, giving millions of Americans more freedom and more control over their own health care and their own future. My plan reduces the rising cost of health care while improving quality and safety; provides new and more affordable coverage options—targeted to those who need it most: low-income children and families, employees of small businesses, and the self-employed; keeps health decisions with patients and physicians—not bureaucrats in Washington, DC; and results in more than 11 million and as many as 17.5 million newly insured Americans. The badly broken medical liability system is raising health care costs for everyone. The cost of medical liability insurance has forced good physicians, hospitals, and health care professionals to practice defensive medicine, curtail their services to a community, and in some case close their doors altogether. If we are going to ensure that health care is affordable and accessible in the future, our system demands a plan for effective and pragmatic medical liability reform that will reduce the number of frivolous lawsuits, lower health care costs for businesses and employees, and help maintain strong physician-patient relationships. My proposal for reform would ensure that injured persons are fully compensated for their full economic losses, while reasonably limiting noneconomic damages to $250 000. It would also reserve punitive damages for cases in which there is egregious conduct, ensure that old cases cannot be brought years after an event, and provide that defendants should pay judgments in proportion to their fault. Frivolous lawsuits and excessive jury awards are a national problem, and the crisis deserves a national solution. I also believe we can reduce costs, reduce preventable medical mistakes, and dramatically improve the delivery of care by increasing the use of health information technologies (IT) in our health care system. America’s physicians and health care professionals are managing 21st-century medicine with 19th-century tools. I set an ambitious 10-year goal for most Americans to have electronic health records, because I believe that health IT can transform health care in America. I have acted to accelerate the use of health IT and challenge the private sector to meet this goal in the next 10 years by doubling the funding for testing these systems in our nation and creating the new Office of the National Coordinator for Health IT to help facilitate the move to electronic health records. My administration is also working with many private organizations like the American Medical Association to develop and adopt the technical standards that will make it possible for sharing information privately and securely among health care providers when authorized by the patient. The most sizable portion of health care spending is devoted to the relatively small number of Americans with chronic illness. We need to do a better job of coordinating the care provided to these individuals. That is why the Medicare legislation that I signed last year will for the first time provide coverage of disease management and chronic care coordination. At the same time, consistent with efforts by my administration to encourage healthful lifestyles and disease prevention, the new Medicare law greatly expands coverage of preventive care, including a new “Welcome to Medicare” physical. Controlling health care costs will help make coverage more affordable. But we must do more to extend coverage to the uninsured. My proposals to expand coverage rely on empowered consumers, rather than on “one-size-fits-all” expansions of government programs that my opponent advocates. He has advanced a proposal that independent analysts estimate will add more than 20 million people to the Medicaid rolls, where their choice of doctor is limited. Vulnerable populations who live in medically underserved areas also have gained greater access to health care through my initiative to open or expand 1200 new health center sites to serve an additional 6.1 million Americans.

Recent Reports on Health Care Reform

T the federal government spent almost $300 billion on health care programs (including Medicare and Medicaid) during Fiscal Year 1996, almost 20 percent of the entire federal budget. In the economy as a whole, health care spending accounts for one-seventh of gross domestic product. Based on size alone, the health care sector should command the attention of public managers and policy analysts. More importantly, health care requires special attention because of its farreaching impact on people's lives, the extent of government involvement in the market, and the highly contentious public debates about health care reform that have occurred over the last four years. The two studies presented here highlight important issues in the health care arena. Medicare is the primary federal government program that finances health care for the elderly. Its exponential growth (Medicare is expected to cost $229 billion in Fiscal Year 2000, 32 percent above 1996 spending) has placed it at the center of budget-cutting proposals. While Republican attempts in the 104th Congress to reduce Medicare spending were defeated, ideas for restraining spending growth have become an important part of the national political agenda. In Restructuring Medicare's Cost-Sharing, Marilyn Moon, a senior fellow at the Urban Institute, examines one option for reducing Medicare spending: increasing the health care costs borne by beneficiaries through higher premiums, deductibles, or co-insurance. Her study is especially relevant for managers and analysts who work in health care organizations or who research health financing alternatives. The number of Americans without health insurance has concerned many managers and analysts in the health care field. The uninsured consume less health care than the insured and suffer from worse health. Hospital care for the uninsured increases insurance costs for everyone else because hospitals pass on the costs of uncompensated care for indigent patients to third party payers, The Kennedy-Kassebaum bill passed by congress in 1996 is supposed to reduce the number of the uninsured by assuring that people who have lost their group coverage or switched jobs can not be denied private insurance because of a pre-existing condition. Gary Claxton and Larry Levitt of the Lewin Group assess the impact of this legislation in Reform of the Individual Health Insurance Market. They conclude that unless the states set limits on the premiums insurers can charge those with pre-existing conditions or subsidize the enrollment of highrisk individuals, the statute will do little to expand coverage. Summaries of each study appear below.