Health Reform Debate Research Articles

Voluntary public health insurance for low-income families: the decision to enroll.

A dominant issue in the health reform debate is whether insurance coverage should be voluntary or mandatory. Clearly, the factors that determine who will seek voluntary coverage are relevant to this policy issue. This article uses experience from Washington State's Basic Health Plan to examine the enrollment choices of low-income families in a state-subsidized voluntary insurance plan offered through managed care organizations. We hypothesize that the decision to enroll, which encompasses the decisions to purchase insurance coverage and to select a particular plan, is influenced by four factors: the family's financial vulnerability, their risk perception, the price of coverage, and the transition costs of enrolling. Our enrollment model is supported by the data and has important implications for the design of voluntary programs. Families who choose to enroll are more likely to have a female head of household, young children, and a family member who has a part-time job and some college education. Higher premiums and availability of other insurance coverage decrease the probability of enrolling.

The Market and Regulation: Where Community Forces Fit

Last year's health reform debate showed us that there is widespread agreement about the problems in our health care system, but very little agreement about solutions. If you followed the national debate, you would have concluded that there are basically two schools of thought about how to reform our health care system. Marketeers believe that we should leave the job mainly to the private sector and build a better functioning health care marketplace. Regulators, on the other hand, believe that only government intervention and government cash can solve our health system's biggest problems. Crossing between these two camps are a large number of very reasonable people who see merit in aspects of both approaches and have been working to try and meld them together by figuring out what the proper role of government is, and what should be left to the marketplace instead. What is fascinating, provocative, and entirely admirable about Bob Sigmond's article is that he reminds us that there has been and apparently still continues to be a third school, one that believes that the answer lies not so much with government or the marketplace, but rather in planned attempts by community leaders at the local level to better and organize care and to make health rather than medical services our top priority. Certainly big problems that take tens of billions of dollars to solve cannot be solved by community initiative--like the problem of the 40 million uninsured. But the values embodied in Sigmond's vision are absolutely the right ones for our health system. The fact is that almost all of our efforts to health services at the community level--however imperfectly covered--have yielded either modest or disappointing results. Some of these have been inspired by government. For example, the kinds of community-based solutions and planning Sigmond advocates were also at the core of the health planning program of the 1970s. How many of you remember HSAs (health systems agencies), SHPDAs (state health planning and development agencies), and SHCCs (statewide health coordinating councils), the state and local health planning organizations charged with rationalizing health services at the local level? Not many, I suspect, because the idea, while well motivated, did not work. Other efforts have been inspired by the private sector. Sigmond himself led perhaps the largest attempt at community-based leadership and planning, a program called The Community Programs for Affordable Health Care, which was funded by the Robert Wood Johnson Foundation. I was the officer at that Foundation responsible for the program at the time. I greatly admired what the program was trying to do, but it failed. It is extremely difficult--if not impossible--for hospitals, doctors, businesses, government agencies, and just regular people in the community to work together when their interests flat out conflict. The closure of a hospital or hospital wing can be a great victory for a community health planner and a catastrophe for that hospital, its board and staff, and neighboring community. We learned in that program that communities have a desire for medical self-sufficiency that almost always puts them at odds with efforts to coordinate or plan--hence the need for external forces, be they the market or the government. Sigmond suggests that we keep trying for a coordinating entity at the community level that can work better than these and other past attempts. But history teaches that coordination without control of resources is a thankless task. Admonition and philanthropic instinct will go only so far in a trillion dollar health care system where leaders of health care organizations are rewarded according to the revenues they bring in and not the community health problems they solve. However, while it is probably wrong to believe that our health care system can be rationalized by some new kind of community entity, in a deeper sense, Sigmond is absolutely right that what ultimately happens in health care will be decided by people--if not coordinating agencies--at the community level. …

The rise and resounding demise of the Clinton plan.

Prologue: The great health reform debate of 1994 ended with a whimper, on the heels of an election that turned out the powerful Democratic majority in the House and Senate and sent some of its most influential members packing. What role did health care reform play in this turning of political fortunes? Was it the unwitting victim? Or was it, in fact, the catalyst? In this paper Theda Skocpol argues that the political reversal of the November 1994 elections might turn out to be one of the biggest turning points in twentieth-century American history and that, far from being a mere casualty, the Clinton plan and Congress's failure to adopt it (or anything else) contributed materially to the revolt of the electorate. This is ironic, Skocpol notes, because the Clinton plan was itself designed as a middle-of-the-road compromise between the market-based and the regulation-based reforms that had been discussed up to that point. The demise of the Clinton plan is notable, she writes, not just as an attempted policy...

Framing the Health Reform Debate

President Clinton's health reform speech to Congress in September 1993 was notable in two ways. Besides being the first U.S. president since Truman to recommend a major overhaul of the American health care system, he also took care to identify the most important moral values that served to justify his proposal. In part, his statement of values was based on the deliberations of an ethics advisory group, one of the thirtyfive working groups convened in the spring of 1993 to advise the White House on the substance of health reform. The optimistic voter tends to assume that the health reform debate is about the policy and economics of health care; the pessimistic voter tends to assume that the debate is a smoke screen behind which the various powerful interest groups will assure that no change in health care cuts too deeply into their profits or privileges. Either way, ethics appears to be a foreign language to the debate. There are, however, important reasons to follow in President Clinton's footsteps and to continue to frame the debate in terms of the moral values at stake. One reason is the greater likelihood of principled compromise. All agree that the health care system eventually resulting from today's debate will be some sort of compromise plan rather than the full implementation of any current proposal. In playing the inevitable game of mix and match, we might end up with a practical plan that continues to promote the most basic moral values at stake; we may end up with a plan that best suits the interest groups with the most power; or we may end up with a plan whose individual elements are defensible, but fail to cohere into a meaningful and workable whole. Continuing to remind ourselves which basic values are at stake, and continuing to hold feet to that fire when important decisions must be voted on, seem a good way to raise the odds of a desirable outcome. Another reason to frame the debate in moral terms is that it ought to engage the public at large and not just the so-called wonks. The technical terms of reform are unfamiliar to even the educated voter--not surprisingly, since we have not seen such a debate in the American political arena within the past fifty years; as recently as the summer of 1991 no one would have predicted that health reform would be a major issue in the 1992 presidential elections. By contrast, the moral values at stake--universal access, reasonable equality of benefits, fairness of burdens, quality and efficiency of care, and so forth--are readily grasped by most people, and form the basis for a serious community discussion of what sort of system would best suit this nation and what sorts of trade-offs ought to be made in implementing it. Starting with the Oregon Health Decisions project and spreading to numerous other states through the grassroots bioethics movement, numerous citizens and communities have become educated participants in the debate, and elected officials have been served notice that thoughtfulness and not mere rhetoric will be demanded of them. …

Looking Back To Move Forward

Looking Back To Move Forward

The beliefs and values shaping today's health reform debate.

Survey results show that the American public comes to the health care reform debate with ambivalent feelings and a relatively low base of specific knowledge. But Americans also hold a set of core values that will shape their response to various proposals for national change. These include (1) a moral commitment to the uninsured; (2) a desire to achieve personal peace of mind; (3) a lack of self-blame; (4) a limited willingness to sacrifice; (5) reasoned self-interest in what changes are enacted; (6) a distrust of government; and (7) a healthy cynicism about the behavior of our major institutions.

Clear-Headed Answers to the Obvious Questions

and a modicum of good luck, the nation can choose the course and move toward the desirable state of affairs‐ lower infant mortality, better education, more effective defense, more readily available drugs, control over Alzheimer’s disease, reduced levels of cancer, lower health costs, and on and on. This is the kind of policy talk I call “crisis mon

The Public and the Controversy Over Abortion

THE ARRIVAL of a new presidential administration in Washington, DC, has been marked by vigorous debate about two major health policy issues—national health reform and abortion. While the national health reform debate will be centered on the passage of a single piece of legislation, the abortion controversy encompasses a number of distinct judicial, legislative, and administrative policy decisions. In each of these areas, the Clinton administration seeks to reverse the trend established in the Reagan-Bush years of increased restrictions on access to abortion and other reproductive services. Within the American medical community and among the general public, few issues are as controversial as abortion. Concern has deepened recently as violent protests and personal attacks on physicians have escalated in the wake of Clinton's decision to remove the gag rule on abortion counseling in family planning centers, and as he and Congress take up several policy initiatives: passing a freedom of

Health Reform Lessons Learned From Physicians In Three Nations

To explore the concerns of practicing physicians as a way to inform the health reform debate, the authors conducted a survey of physicians in the United States, Canada, and Germany. Survey results indicate that U.S. physicians are most likely to view affordability as the greatest barrier to access to care for their patients. However, unavailability of services and long waiting times were cited most often by Canadian physicians. German physicians did not cite access problems as frequently as Canadian physicians did; other measures of satisfaction were closer to U.S. levels, suggesting fewer trade-offs if the United States were to adopt aspects of the German health care system.