Expanding Health Care Coverage Research Articles

How it's done: Keys to implementation of delivery system reform

The vision of Obamacare – including the expansion of health care coverage to millions more Americans – rests in no small part on the reduction of health care waste and the spread of cheaper, more sustainable models of health care delivery. Though this will require thoughtful policy, powerful payment incentives and innovative new models of care delivery, it will also require all health care industry stakeholders to execute rapid, large-scale change in practice much more effectively. This paper offers nine strategies for more successfully managing this transformative change.

The Patient Protection and Affordable Care Act: Better Coverage, Worse Access. Will It Really Improve Patient Safety?

The Patient Protection and Affordable Care Act: Better Coverage, Worse Access. Will It Really Improve Patient Safety?

Medicaid and the Affordable Care Act after the Supreme Court Decision

The June 2012 Supreme Court decision (National Federation of Independent Business [NFIB] v. Sebelius, 2012) upholding much of Affordable Care Act (ACA) marked major step forward in century-long effort achieve universal health care coverage in United States. As Elizabeth Clark, NASW's chief executive officer, noted, decision gives nation a great opportunity expand coverage and access, and bring spiraling health care costs under control (Clark, 2012). This is truly reason for celebration (Dworkin, 2012). Leading up decision, much attention had focused on question of constitutionality of individual mandate, which requires Americans maintain 'minimum essential health insurance coverage' or '[s]hared responsibility payment' Federal (NFIB v. Sebelius, 2012, p. 1). The government had argued that mandate could be justified under two clauses in Constitution: so-called commerce clause, which gives Congress right regulate interstate commerce, and clause giving Congress right lay and collect taxes (cited in Dworkin, 2012). In surprising decision, Chief Justice John Roberts, speaking for majority, ruled that mandate could not be justified under commerce clause, but it could under power of Congress and spend (Jost, 2012). Although Congress cannot require individuals purchase insurance, it can tax people who fail do so (lost, 2012). Even more surprising than decision upholding mandate was court's ruling on Medicaid. As part of its strategy expand health care coverage, Obama administration included in ACA provision requiting states extend Medicaid coverage individuals earning below 138 percent of federal poverty line (FPL), nearly $30,000 for family of four (Madrick, 2012). States failing do this would be denied all federal funding for Medicaid. By seven-to-two margin, however, Supreme Court ruled this unconstitutional, reasoning that because many states rely on Medicaid funds balance their budgets, this provision left the states no real option decline (Dworkin, 2012). The court's decision now gives states option of refusing expand coverage without losing all Medicaid funds. This was first time court has struck down conditions on federal grants states that it determined 'cross line from enticement coercion' (Swendiman & Baumrucker, 2012, p. 10). This decision could have dramatic and adverse impact on individuals living near and below FPL ($11,170 for single individual in 2012; $19,090 for family of three), particularly childless, nonelderly adults, who in most states have not been eligible for Medicaid but would be under ACA (Rosenbaum & Westmorland, 2012). Under ACA, individuals with incomes below 100 percent of FPL are not eligible for tax credits assist them in buying insurance through new health exchanges. The assumption was that these people, as well as individuals with incomes between 100 percent and 133 percent of FPL, would be covered through Medicaid expansion (Community Catalyst, 2012). Although individuals with incomes between 100 percent and 133 percent of FPL will still be eligible for credits, this may not be enough to make coverage truly affordable (Community Catalyst, 2012). In light of court decision, individuals with incomes below 100 percent of FPL are no longer guaranteed coverage through Medicaid or exchanges (Angeles, 2012). In median state, cutoff point for receiving Medicaid for working parent is around $12,000 for family of three and around $7,100 for an unemployed parent (Angeles, 2012). Individuals earning above this will be ineligible for Medicaid. At same time, according Congressional Budget Office (CBO, 2012), around two-thirds of people previously estimated become eligible for Medicaid as result of ACA will have income too low qualify for exchange subsidies. …

Optimizing Social-Affiliation Networks of the Players in a Health Care Game

Evan V. Goldstein The U.S. Supreme Court’s June 2012 decision to uphold the Patient Protection and Affordable Care Act of 2010 has sparked an intense domestic policy debate over health care reform, including the forthcoming expansion of health care coverage to millions of Americans. Despite partisan gridlock at the national policy level, opportunities exist within the current health care system to coordinate resources, slow the rise of public health care expenditures, and expand access to care. paper explores one such opportunity by introducing a simple game-theoretic model of patient interaction to show how the constraints on a network structure of health care provider organizations and the flow of information between providers and patients within that network generated a socially suboptimal level of care in Cuyahoga County, Ohio, in 2008. Specifically, the paper will focus on the evolving social-affiliation network of both health care provider organizations and the indigent and uninsured patient populations within a threecity interest area of Cuyahoga County. e primary challenge for charity care in Cuyahoga County is shown to be structural (in the network-theoretic sense), revealing an insidious geographical paradox: despite the spatial proximity of several viable charity care providers, many patients over-rely on select health care organizations and underuse other available resources. Ultimately, the model illustrates how local government-initiated coordination among health care providers and geographical expansion of the health care providers available to patients should remedy the socially suboptimal uncompensated care consumption problem and promote the attainment of a socially optimal consumption level. analysis will lead to a discussion of coordination among health care providers and the role of local government as drivers

Extending contraceptive coverage under the Affordable Care Act saves public funds

BackgroundThe Affordable Care Act (ACA) will expand health care coverage to low-income Americans. Contraception services are a mandated component of ACA plans. Study DesignA decision-analytic model was developed to compare the costs and outcomes of the current versus the proposed plan for contraceptive coverage (Federal Poverty Level=185% vs. 399%, respectively) over 5 years. The perspective adopted was that of Oregon state insurance providers. The primary outcomes were number of pregnancies averted, health costs and quality adjusted life years (QALYs). Contraceptive failure rates, costs, projected insurance coverage, contraception use and pregnancy outcome data were obtained from the published literature. Sensitivity analyses were performed for all variables. ResultsExtending contraceptive coverage both saves money and improves outcomes for Oregon state insurance plan providers. The proposed policy would prevent an additional 72 pregnancies per 1000 women over 5 years. Extending coverage is cost-effective, saving an additional $489 per woman enrolled over 5 years while increasing QALYs. ConclusionsExpanding contraceptive coverage under the Affordable Health Act is cost-effective for Oregon state insurance providers.

Cash transfer schemes and the health sector: making the case for greater involvement

Cash transfer schemes can be important contributors to human development and social protection. Although they have significant health benefits, they have rarely been considered an integral part of the health policy portfolio. We believe that a case can be made for greater health sector involvement in the design, implementation and evaluation of such schemes. Cash transfers (CTs) are attracting increasing interest as effective and ac ceptable means of improving the welfare of disadvantaged households in low- and middle-income countries. They give households regular, predictable amounts of money in the form of pensions, child benefits or regular household grants. Although such social protection mechanisms are often the norm in highincome countries, CTs have historically been rare in low- and middle-income countries. Instead, governments and donors have typically preferred supplyside interventions (expanding health care coverage, for example) or in-kind transfers of goods or food. Financial shocks during the late 1990s, however, triggered a global shift towards social protection schemes more closely resembling European models (emphasizing social security rather than assistance as a last resort). This shift also reflected a desire to correct shortcomings associated with reforms advocated under the Washington consensus, characterized by the dismantling of State services and their replacement with segmented private services.

Patterns of Colorectal Cancer Test Use, Including CT Colonography, in the 2010 National Health Interview Survey

Recommended colorectal cancer (CRC) screening tests for adults ages 50 to 75 years include home fecal occult blood tests (FOBT), sigmoidoscopy with FOBT, and colonoscopy. A newer test, computed tomographic (CT) colonography, has been recommended by some, but not all, national organizations. We analyzed 2010 National Health Interview Survey data, including new CT colonography questions, from respondents ages 50 to 75 years (N = 8,952). We (i) assessed prevalence of CRC test use overall, by test type, and by sociodemographic and health care access factors and (ii) assessed reported reasons for not having a CRC test. The age-standardized percentage of respondents reporting FOBT, sigmoidoscopy, or colonoscopy within recommended time intervals was 58.3% [95% confidence interval (CI), 57.0-59.6]. Colonoscopy was the most commonly reported test [within past 10 years: 54.6% (95% CI, 53.2-55.9)]. Home FOBT and sigmoidoscopy with FOBT were less frequently used [FOBT within past year: 8.8% (95% CI, 8.1-9.6); sigmoidoscopy within past 5 years with FOBT within past 3 years: 1.3% (95% CI, 1.0-1.6)]. CT colonography was rare: 1.3% (95% CI, 1.0-1.7). Increasing age, education, income, having health care insurance, and having a usual source of health care were associated with higher CRC test use. Test use within recommended time intervals was particularly low among individuals ages 50 to 64 years without health care insurance [21.2% (95% CI, 18.3-24.4)]. The most common reason for nonuse was "no reason or never thought about it." About 40% of Americans ages 50 to 75 years do not meet the recommendations for having CRC screening tests. Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality.

Highlights of This Issue

Recommended colorectal cancer (CRC) screening tests for U.S. adults, ages 50-75, include the home fecal occult blood test (FOBT), sigmoidoscopy with FOBT, and colonoscopy. Shapiro and colleagues analyzed 2010 National Health Interview Survey data to assess the prevalence of CRC test use, and the reported reasons for not having a CRC test. The authors found that only 58.3% of respondents reported FOBT, sigmoidoscopy with FOBT, or colonoscopy at recommended time intervals. Increasing age, education, income, having health insurance, and having a usual source of health care were all associated with higher CRC test use. Over 40% of U.S. adults in this age group do not meet recommendations for CRC screening tests. Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality.Lymphoma patients experience sleep problems that could be managed with aerobic exercise. Courneya and colleagues randomized lymphoma patients to usual care or 12-week supervised aerobic exercise training (AET). Results show that AET improved global sleep quality in several subgroups of lymphoma patients – those with indolent non-Hodgkin lymphoma, patients receiving chemotherapy, obese patients, and poor sleepers at baseline. If replicated in larger and more focused trials, AET may be an attractive option to manage sleep dysfunction in these patients.Studies have suggested an increased risk of gastric cancer in relation to the consumption of pickled food. Ren and colleagues conducted a meta-analysis that compared gastric cancer risk in pickled food users versus nonusers, or versus those in the lowest reported category of use. A significant increased risk of gastric cancer was observed in 30 of 50 case-control studies. These results suggest a higher risk of gastric cancer associated with pickled food intake, and may offer ways to reduce gastric cancer incidence.Cigarette smoking and smokeless tobacco use are high in the Alaska Native (AN) population. Benowitz and colleagues investigated possible mechanisms of increased cancer risk by studying levels of nicotine and tobacco-specific nitrosamines in tobacco products and biomarkers of tobacco toxicant exposure in a southwestern AN population. While nicotine concentrations were highest in cigarette tobacco, nicotine exposure was highest among users of igmik, a homemade smokeless tobacco preparation. This study reveals the high addiction risk potential of igmik, and sheds light on the increased cancer risk of various forms of tobacco use by the AN people.

The readiness of addiction treatment agencies for health care reform

The Patient Protection and Affordable Care Act (PPACA) aims to provide affordable health insurance and expanded health care coverage for some 32 million Americans. The PPACA makes provisions for using technology, evidence-based treatments, and integrated, patient-centered care to modernize the delivery of health care services. These changes are designed to ensure effectiveness, efficiency, and cost-savings within the health care system.To gauge the addiction treatment field’s readiness for health reform, the authors developed a Health Reform Readiness Index (HRRI) survey for addiction treatment agencies. Addiction treatment administrators and providers from around the United States completed the survey located on the http://www.niatx.net website. Respondents self-assessed their agencies based on 13 conditions pertinent to health reform readiness, and received a confidential score and instant feedback.On a scale of “Needs to Begin,” “Early Stages,” “On the Way,” and “Advanced,” the mean scores for respondents (n = 276) ranked in the Early Stages of health reform preparation for 11 of 13 conditions. Of greater concern was that organizations with budgets of < $5 million (n = 193) were less likely than those with budgets > $5 million to have information technology (patient records, patient health technology, and administrative information technology), evidence-based treatments, quality management systems, a continuum of care, or a board of directors informed about PPACA.The findings of the HRRI indicate that the addiction field, and in particular smaller organizations, have much to do to prepare for a future environment that has greater expectations for information technology use, a credentialed workforce, accountability for patient care, and an integrated continuum of care.

Healing Health Care Finances

Health care presents a daunting fiscal challenge in both advanced and emerging economies. This paper examines public spending pressures in health care over the next several decades and provides recommendations for reform. Using a methodology that improves upon earlier studies, the paper finds that public health spending will rise by 3 percent of GDP over the next 20 years in advanced economies, and in emerging economies, by 1 percent. For advanced economies, the most promising reforms to contain the spending of growth in an efficient and equitable manner involve a mix of budget controls and efficiency-enhancing reforms, including the introduction of market mechanisms and public management reforms that strengthen incentives for the provision of cost-effective care. Simulations show that these reforms could significantly reduce the fiscal burden of health care over the next 20 years. For emerging economies, the expansion of health care coverage should be based on a package of the most essential health services to ensure fiscal sustainability.

The patchwork: Health reform, American style

0277-9536/$ e see front matter 2010 Elsevier Ltd. doi:10.1016/j.socscimed.2010.10.016 American health care rightly has been characterized as a “paradox of excess and deprivation” (Enthoven & Kronick, 1989, p. 29). The United States spends more on medical care than any country in the worlddover $2.5 trillion or 17% of its gross domestic product as of 2009. At the same time, the U.S. is the only rich democracy where a substantial portion of its residents lacks health insurance coverage. Fifty-one million Americans (nearly 17% of the population) go without health insurance at any given time (Denavas-Walt, Proctor, & Smith, 2010). Another twenty-five million American adults are “underinsured,” covered by insurance policies that inadequately protect them against the high costs of medical care (Schoen, Collins, Kriss, & Doty, 2008). Serious problems in access to and the costs of American medical care are nothing new, but meaningful health reform has long been elusive. During the twentieth century, reformers repeatedly failed to secure enactment of universal health insurance (Morone & Blumenthal, 2009; Starr, 1982). The U.S. last adopted a major expansion of health care coverage in 1965. Consequently, the nation’s uninsured rate hasmarched upward in recent decades. The enactment of the 2010 Patient Protection and Affordable Care Act thus stands as a historic milestone and a break from the stalemated past (Kaiser Family Foundation, 2010; Oberlander, 2010). This essayaims to illuminate the 2009e2010 struggle overhealth reformand evaluatewhat type of reform that struggle produced.We begin by highlighting the considerable obstacles that President Obama and Democrats faced in pursuing major health care legislation and the political strategies they developed to overcome those obstacles. We then turn to the legislative result, a patchwork of

Health care reform in 2010: transforming the delivery system to improve quality of care

Although the American health care system is the most expensive in the world, it delivers inconsistent (and sometimes poor) quality of care. Recent health care legislation contains several delivery system reforms that will attempt to address these issues. We review these programs and discuss the implications for practicing urologists. We evaluated the medical, legal, and public policy literature (both print and electronic) related to contemporary health care reform efforts. We summarized the Patient Protection and Affordable Care Act of 2010 (PPACA) and examined four cost-containment and/or quality-improvement mechanisms related to Medicare payment policy that will be implemented by this recently passed law. The PPACA will expand health care coverage and promote bundled payment systems, accountable care organizations, and the patient-centered medical home as the vehicles for containing cost and improving health care quality. The legislation will also establish an independent commission to enact cost-containment policy, which may have significant implications in terms of physician reimbursement. Although the recent health care legislation broadens coverage for millions of Americans, there are limited data demonstrating the effectiveness of the cost-containment and quality-improvement mechanisms established by this law. Results from recently initiated pilot programs will emerge over the coming years, and it remains to be seen how health care costs and quality will be affected.

The impact of ethnicity on attitudes toward health care reform in New Mexico

Latinos tend to have significantly lower levels of access to general and top quality medical care than do non-Latino whites, and although disparities in access to health care have diminished for all other minority groups over time, they have widened for Latinos. Given these trends, current attempts to provide universal health care at both the national and state levels across the United States have large implications for the health status of Latinos. The objective of this analysis is to determine whether Latinos have different attitudes regarding health reform than non-Latino whites. Our data are from a statewide random digit dialing telephone survey of New Mexico residents, age 18 and older, conducted in the Fall of 2007. With a Latino population of 44% and ongoing health care reform efforts by the state legislature, New Mexico is an ideal location for this analysis. After controlling for a host of individual level factors, our findings suggest that while Latinos are less likely to identify health care as a salient state issue relative to the economy and crime, they are more likely than non-Latino whites to believe affordable health care programs are important. Finally, Latinos view employers, more than government or individuals, to be responsible for expanding health care coverage.

OECD 국가들의 건강수준 결정요인

This article examines social determinants of population health in OECD countries, where life years, infant mortality, and PYLL are used as proxy variables of health. The unit of analysis is a country which is the OECD affiliate. A panel regression estimation is chosen as a method, using OECD Health Data. The results are: the increasing national health expenditure affected positively to improve population health. Education was rather a significant determinant of health than income level. The government direct investment for public health did not contribute positively to enhance population health. The expansion of health care coverage was working positively for improving health, but with a time lag. The supply of doctors was a most influential determinant of health. In case of Korea, the coverage expansion of health care was the most important determinant of health. The supply of doctors was, however, not a positive factor for better health, which is different result with the case of OECD countries.

Costs to Expand Healthcare Coverage Might Be Offset Partially by Savings

As U.S. legislators consider expanding health insurance coverage to people younger than 65, investigators assessed some possible cost consequences. In an analysis that used data from a longitudinal nationally representative survey and Medicare claims files, Medicare spending was calculated for older adults (age, ≥65) who had been either continuously insured or at least intermittently uninsured …

Eliminating “Waste” in Health Care

PRESIDENT OBAMA IS THE MOST RECENT IN A LONG LINE of US presidents to seek reductions in health care spending through elimination of “waste.” However, the stakes this time are unusually high—the president has reported that eliminating waste is needed to fund two-thirds of the approximately $900 billion needed (over 10 years) for expanded health care coverage. To achieve this goal requires defining waste, identifying contexts in which it occurs, determining why it occurs, and implementing policies that prevent reoccurrence. Defining waste in medical care is not simple. Consider, for example, a patient who has experienced frequent, intermittent headaches for several weeks. Her physician thinks it is unlikely that the headaches are caused by a brain tumor or lesion (less than 1 chance in 10). A magnetic resonance imaging scan would provide more definite information. If the physician orders the scan, is that waste? What if the chances were 1 in 100 or 1 in 1000? What if the patient is so anxious about the headaches that she has difficulty with daily functions? Should that affect the definition of waste? As another example, consider 10 members of a college football team who are found to have a disease that has 2 possible interventions. Bed rest, fluids, and over-the-counter medications for relief of symptoms would result in recovery of all 10 patients in about 2 weeks; administration of a new, expensive drug would likely cure 7 patients within 2 or 3 days, send 1 patient to the hospital, and have no effect on the others. Is it wasteful to give the drug—or not to give it? These examples lead to considering 2 possible definitions of waste in medical care. Medical waste is defined as any intervention that has no possible benefit for the patient or in which the potential risk to the patient is greater than potential benefit. Economic waste is defined as any intervention for which the value of expected benefit is less than expected costs. The proportion of care deemed wasteful using the medical definition is much smaller than that deemed wasteful using the economic definition. Medical waste could occur only if the physician is misinformed, if the patient is misinformed and the physician succumbs to patient demands, or if the physician behaves unethically. Economic waste is much more common because of third-party payment. A conscientious clinician treating an insured patient would tend to recommend any intervention with a potential benefit greater than the potential risk. Two ubiquitous aspects of medical care make identification of waste particularly problematic. First, there is little certainty in medicine. Implicitly, if not explicitly, physicians are usually dealing with probabilities. Many interventions appear to have been wasteful in retrospect, but that is not the correct criterion; only prospective probability of success is relevant. The oft-heard promise “we will find out what works and what does not” scarcely does justice to the complexity of medical practice. Some interventions are undoubtedly useless, but those that might help some patients are much more common. Second, patients differ in unpredictable ways. The same drug given to patients with the same diagnosis often has different effects, ranging from rapid cure to serious adverse reaction. Any effort to reduce costs on a large scale requires consideration of economic waste. Where in medical practice is economic waste likely to be found? Almost everywhere. Some patients do not receive sufficient screening because of lack of insurance, inertia, or fear, but for the US population as a whole, the error is probably on the side of excess screening. On a per capita basis, patients in the United States receive almost 3 times as many magnetic resonance imaging scans as those in Canada. Are the benefits of extra scans enough to justify the extra cost? Repeated testing is another area with high potential for economic waste. There is usually little scientific foundation for the appropriate interval between tests and even less economic analysis of benefits and costs of alternative intervals. For a variety of reasons, including pressure from patients, physicians prescribe brand-name drugs when generic medications would be as effective or no drug at all would be best. An analogous situation may be the choice between a high-cost device or procedure and a less expensive alternative. For example, high-cost drug-eluting stents may be the better choice for some patients, but others would do just as well with less expensive bare-metal stents. Some patients are hospitalized for what might be wasteful reasons. For example, the patient’s insurance coverage might be better in hospital, compensation to the physician

Productivity Rewards and Pay Illusions Caused by Health and Retirement Benefit Cost Increases

In summer 2009, health care reform seems almost within reach. President Barack Obama is urging the Congress to pass bills, and both the House and Senate are trying to deliver. Everyone agrees on the necessity of reform, but that’s where the agreement ends. Most of the ongoing discussions about who should pay for health care legislation have proposed employer coverage mandates, limitations on health benefit tax preferences, taxation of health insurers and 'play-or-pay' provisions, all of which would distribute the costs of expanded coverage among employers and, through them, to their workers in the form of slower wage growth. An important - but often overlooked - point in these discussions is that health costs paid by employers are part of the compensation paid to workers. Compensation includes wages, employer contributions to Social Security and Medicare, the cost of any health insurance coverage for workers and their dependents, and contributions to any pension plans, 401(k) plans and other capital accumulation programs. While many of the proposals for health reform are looking to employers to fund much of the cost, there has been little focus on the links among wages, compensation and the cost of employer-sponsored health and retirement benefits. No one has talked much about how higher health benefit costs to employers would affect the paychecks workers bring home. The analysis in this report projects five scenarios that illustrate the importance of controlling health costs. In our baseline scenario, we manage to cut health benefit cost inflation rates roughly in half and do not expand health insurance coverage. In that scenario, wage growth rates are projected to be roughly equivalent to those of the 1990s for the next couple of decades. Under an assumption that we control health cost inflation but expand coverage by means of an employer play-or-pay mandate, the effect on wage growth patterns would be negative at the bottom of the earnings distribution and mildly negative in the middle of the earnings distribution for a while. But after 2015, wage growth rates would return to the healthier levels of the 1990s. Bringing health costs under control allows more resources for expanded coverage. If we expanded health insurance coverage but our current health cost inflation rate continued unabated, the higher overall costs would result in falling wages at the bottom of the earnings spectrum and very slow wage growth on up the earnings distribution. These dismal wage outcomes would persist over at least the next couple of decades, possibly longer. The next scenario considers the real possibility that health inflation increases as a result of expanded insurance coverage offered under reform. Looking back at the implementation of Medicare, this is exactly what happened. This scenario combines expanded health care coverage with accelerated health inflation rates. In this case, the higher costs would drive disposable wages downward across most of the earnings spectrum, although the declines would be steepest for lower-earning workers. These depressed conditions would persist over the entire projection period. Fixing what is broken in our health care system is about more than expanding health insurance coverage or deciding whether taxing employer-sponsored health benefits is good or bad policy. No matter how health care reform is financed - whether by employers, who pass the costs on to workers, or taxpayers - the bill will be unaffordable unless costs are brought under control. Our current health care system is embedded with incentives that encourage providers to dispense an ever-expanding menu of treatments and medications, even where there is little evidence of their efficacy. Our health care system already costs 40 percent to 100 percent more than its counterparts in other developed countries and is growing twice as fast.

The democratization of health in Mexico: financial innovations for universal coverage

In 2003, the Mexican Congress approved a reform establishing the Sistema de Protección Social en Salud [System of Social Protection in Health], whereby public funding for health is being increased by one percent of the 2003 gross domestic product over seven years to guarantee universal health insurance. Poor families that had been excluded from traditional social security can now enrol in a new public insurance scheme known as Seguro Popular [People's Insurance], which assures legislated access to a comprehensive set of health-care entitlements. This paper describes the financial innovations behind the expansion of health-care coverage in Mexico to everyone and their effects. Evidence shows improvements in mobilization of additional public resources; availability of health infrastructure and drugs; service utilization; effective coverage; and financial protection. Future challenges are discussed, among them the need for additional public funding to extend access to costly interventions for non-communicable diseases not yet covered by the new insurance scheme, and to improve the technical quality of care and the responsiveness of the health system. Eventually, the progress achieved so far will have to be reflected in health outcomes, which will continue to be evaluated so that Mexico can meet the ultimate criterion of reform success: better health through equity, quality and fair financing.

USA - Expanding health care coverage and lowering costs – health savings accounts

USA - Expanding health care coverage and lowering costs – health savings accounts

U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey

BACKGROUNDPhysician opinion can influence the prospects for health care reform, yet there are few recent data on physician views on reform proposals or access to medical care in the United States.OBJECTIVETo assess physician views on financing options for expanding health care coverage and on access to health care.DESIGN AND PARTICIPANTSNationally representative mail survey conducted between March 2007 and October 2007 of U.S. physicians engaged in direct patient care.MEASUREMENTSRated support for reform options including financial incentives to induce individuals to purchase health insurance and single-payer national health insurance; rated views of several dimensions of access to care.MAIN RESULTS1,675 of 3,300 physicians responded (50.8%). Only 9% of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42% preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance.CONCLUSIONSThe vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.