Proposed National Health Insurance Research Articles

Health Policy, Health Insurance, and the Social Contract

Ever major western democracy is currently engaged in renegotiation of the social contract, which serves as the foundation for the social welfare state. This between the State and society represents a negotiated agreement between the government and citizens over respective responsibilities and duties. The agreement specifies what benefits government agrees to provide to citizens in return for tax-based financing of these benefits; it also recognizes the role of government in designing and administering the programs, which ultimately provide the desired benefits. This essay examines the development of the social contract as it relates to the development of the structure of the health care system in the United States and the performance of that system in terms of providing health services. It argues that the social-political debates in Europe had a very limited influence on the development of the American health care system and that the transatlantic connection may have greater applicability in the health care debates of the early 21st century than it did in the 18th, 19th, and 20th centuries. The current system of managed care in the United States is being adapted in Germany and other European countries as opposed to the adaptation of the European health care model in the United States. In other words, many political leaders and academics foresee a great similarity in the future between the U.S. and European health care systems. Others would argue that the traditions and practices of these countries differ sufficiently that a narrowing of the gap is neither desirable nor feasible. Until the 20th century, the American health care system was essentially a non-system. At the same time, there was very little support in the United States for government financing of health care programs similar to those being developed and adopted in Europe. The defeat of national health insurance proposals in the early 1900's through 1946 helped to bolster the position of private insurance companies and organized medicine. With the passage of Medicare and Medicaid, the role of the federal government was fundamentally changed. These programs represented a major change in the government's approach to the design, financing, and delivery of health care. Subsequent to Medicare and Medicaid, Congress enacted the Health Maintenance Organizaation Act of 1973. Federal involvement in health care was augmented in 1986 with the enactment of the Emergency Medical Treatment and Active Labor Act of 1986, the Health Insurance Portability and Accountability Act of 1996, and the Children's Health Insurance Program of 1997. During the period between 1865 and 1995, the influence of the transatlantic connection was very limited. Social policy makers in the United States were aware of the innovations and programs being adopted in Europe. Some of these policy proposals were introduced in the United States and rejected. In contrast, concepts of employer mandates and compulsory insurance were commonplace and fully accepted by most segments of society in Europe. Over the last fifteen years, with the growing economic pressure on the European social welfare state, there is growing pressure to reform the health care system and adopt some of the U.S. concepts of managed care. The managed care experience of the United States and the employment crisis of Europe may be leading to a convergence in the organization and financing of our respective health care systems.

“It's the Health-Care Costs, Stupid!”: Ideas, Institutions, and the Politics of Organized Labor and Health Policy in the United States

In 1978, organized labor formally abandoned its longstanding commitment to public-sector solutions to achieve universal health care. Over the following fifteen years, it embraced private-sector solutions premised on a government mandate that would require employers to pay a portion of their employees health insurance premiums. In many respects, this about-face on the part of organized labor is neither remarkable nor puzzling. After all, labor's prior commitment to national health insurance1. The term national health insurance has many meanings. As used here, it refers to health-care reform proposals modeled on the Canadian experience in which the government replaces private insurance with its own public insurance system, thus eliminating the commercial health insurers. Commonly referred to as “single-payer” plans today, proposals for national health insurance can vary enormously on important details like financing, budgeting, taxation, and the role of individual states. had coexisted with its deep and abiding attachment to the private welfare state of job-based benefits dating back to the 1940s.2. Donna Allen, Fringe Benefits: Wages or Social Obligation? (Ithaca, NY: Cornell University Press, 1964); Joseph W. Garbarino, Health Plans and Collective Bargaining (Berkeley: University of California Press, 1960); Raymond Munts, Bargaining for Health: Labor Unions, Health Insurance, and Medical Care (Madison: University of Wisconsin Press, 1967); Beth Stevens, “Labor Unions, Employee Benefits, and the Privatization of the American Welfare State,” Journal of Policy History 2 (1990): 233–60; and David Rosner and Gerald Markowitz, “Hospitals, Insurance, and the American Labor Movement: The Case of New York in the Postwar Decades,” Journal of Policy History 9 (1997): 74–95. American labor unionists have tended to be strident pragmatists compared to their European counterparts, who have been more consistently animated by a larger social democratic vision. Furthermore, American unions have a long history of deferring to the Democratic party.3. Indeed, some analysts characterize labor's relationship with the Democratic party as a “barren marriage” or “abusive relationship.” Mike Davis, Prisoners of the American Dream: Politics and Economy in the History of the U.S. Working Class (London: Verso, 1986), 52; and Joel Rogers, “The Folks Who Brought You the Weekend: Labor and Independent Politics,” in Audacious Democracy: Labor, Intellectuals, and the Social Reconstruction of America, ed. Steven Fraser and Joshua B. Freeman (Boston: Mariner, 1997), 255. Arguably, labor's support for national health insurance had been primarily rhetorical since the early 1950s, when the industrial unions began to rely on collective bargaining to achieve health-care security for their members. Once President Jimmy Carter and Sen. Edward Kennedy (D-MA) retreated from national health insurance in the face of the new anti-government, dereg- ulatory, deficit-conscious environment that emerged in the mid-to-late 1970s, one may conclude that labor “naturally” abandoned ship as well.

Canadian health care and its vulnerabilities.

,H TOW CANADIAN HEALTH CARE IS VIEWED IN THIS country is a reflection of the dilemmas that confront U.S. medicine. Medicare first attracted the attention of American observers during the 1970s, when national health insurance proposals were being considered by the Congress (Marmor 1993). Following this episode, interest in system quickly subsided among all but a small coterie of health policy specialists. When health care reform regained preeminence on the American political agenda in the early 1990s, Canadian practices once again emerged as rich fodder for lessons designed to guide public policy development. As political scientist Antonia Maioni stated: Canada's health insurance system ... [became] a useful target and a political weapon in the reform debate, alternatively used as a model of what American health reform ought to aspire to, or as an ominous warning about the problems inherent in government in a national health insurance program (Maioni 1994, 2-3). Today the backdrop for American interest in health system is the controversy over managed care. U.S. health care has entered an unmistakably chaotic period, marked by rampant corporatism, a swelling wave of complaints against insurance gatekeepers, and increasing privatization of Medicaid and Medicare through large-scale public contracts

An Unusual View Of Health Economics

An Unusual View Of Health Economics

米国のヘルスケアリフォーム: その後

1994年,クリントン政権による国民皆保険導入へ向けての医療システム改革案が廃案となった。その背景には,医療政策をめぐる利益者集団の問で国民皆保険に対するコンセンサスが得られなかったことが最も大きな要因の一つとして挙げられる。政府は1990年代の民間セクターにおける医療費抑制に対する著しい成果と医療の質を体系的に測定しようとする多くの努力を背景に,1997年の予算決議案をもって,政府主導型のヘルスケアリフォームではなく,むしろこうした民間医療保険システムの積極的な公的医療保険への導入に踏み切った。受益者が診療報酬によるインデムニティ型の伝統的メディケアやメディケアHMOの枠組みを超えて,POSやPPOといったマネジドケアプランを自由に選択することができる「メディケア+チョイス」や,受益者の医療サービスに対するアクセスビリティーの確保,プログラムの効率化,そして急増するメディケイドの支出に対する抑制策としてのメディケイド・マネジドケアは,そうした政府による政策努力の結果である。市場メカニズムを中心としたヘルスケアリフォームが進む中,国民皆保険の導入という当初の政策目標は風化しつつあり, あらゆる財に関して「大きな」政府の市場への介入を嫌う傾向にある米国社会において,短・中期的にみて平均的米国人が医療サービス市場を放棄し,政府主導の国民皆保険制度を受け入れるとは予測しがたい。したがって当面の米国政府に課せられた課題は,医療資源配分の効率化を徹底させるためのリスク調整システムを開発すること,医療の質の改善とその結果である生産の効率化に向けてその測定方法を確立すること,そして低所得者とその扶養家族,高齢者,慢性疾患をもつ患者等公的医療保障を受ける資格のない境界線上の人々に対する特別優遇措置を設定することであろう。

Willingness to pay for health insurance in a developing economy. A pilot study of the informal sector of Ghana using contingent valuation

In the midst of high cost of health care both at the macro and micro levels, health insurance becomes a viable alternative for financing health care in Ghana. It is also a way of mobilising private funds for improving health care delivery at the macro level. This study uses a contingent valuation method to assess the willingness of households in the informal sector of Ghana to join and pay premiums for a proposed National Health Insurance scheme. Focus group discussions, in-depth and structured interviews were used to collect data for the study. There was a high degree of acceptance of health insurance in all the communities surveyed. Over 90% of the respondents agreed to participate in the scheme and up to 63.6% of the respondents were willing to pay a premium of ¢5000 or $3.03 a month for a household of five persons. Using an ordered probit model, the level of premiums households were willing to pay were found to be influenced by dependency ratio, income or whether a household has difficulty in paying for health care or not, sex, health care expenditures and education. As income increases, or the proportion of unemployed household members drop, people are willing to pay higher premiums for health insurance.

Medicine's dilemmas: infinite needs versus finite resources

No cost is too great to save a life, but somebody has to pay health care issues of the 1990s health - the object of an infinite quest health care is a cultural affair resource allocation in health care medicine and management - a synthesis the past as prologue National Health Insurance proposals To The States Respectively Promote the General Welfare Together ... or Hang Separately health care forces for the 21st century.

NATIONAL HEALTH CARE AND QUALITY OF SERVICE: LESSONS FROM MEDICAID

Much recent public debate centers around failures in the U.S. health care system. Studies indicate that as many as 33 million Americans are without health insurance, while health care expenditures continue to out‐strip GNP growth. Numerous proposals for national health insurance have surfaced in response to these apparent shortcomings. The various proposed health insurance structures are not always based upon careful economic evaluation of incentive schemes and of the full range of potential effects. This paper examines results of recent Medicaid system studies so as to shed light upon the outcomes one can expect from national health insurance plans possessing similar incentive structures. The results here have potentially useful policy implications.

How will children and pregnant women fare under current national health insurance proposals?

To compare the following five major national health insurance proposals and their implications for children and pregnant women: the MAtsui "play or pay" bill (HR 3393); the Russo Canadian-type bill (HR 1300); the Rockefeller "play or pay" bill (S 1177); the Stark Medicare-type bill (HR 650); and the president's market reform proposal. Using an analytic framework developed by the Association of Maternal and Child Health Programs, we examine the differences among the five proposals in basic approach, eligibility and enrollment, benefits, cost-sharing requirements, provider reimbursement, and cost-control measures. All of the plans, except for President Bush's, would provide coverage for virtually all children and pregnant women, using a combination of private and public approaches. President Bush's market approach provides financial incentives to purchase health insurance benefit plans that states can design within actuarial limits. The remaining four plans strive for uniformity in benefits, covering physician and hospital services in a manner similar to most plans today. Preventive care benefits extend beyond what has been offered in the past. The four plans differ sharply in their coverage of extended care services, with the Matsui and Russo bills covering the most generous package of benefits. The Rockefeller and Stark plans, on the other hand, require less cost-sharing for their basically preventive and primary care plans. Most of the health insurance proposals are aimed at extending preventive and primary care health insurance plans to more uninsured Americans. Only the Matsui bill devotes significant attention to developing a comprehensive benefit plan for children and pregnant women. Additional attention should be directed at extended care services for those with special health care needs, the future role of Medicaid, and the public health system infrastructure.

The Practice and Ethics of Risk-Rated Health Insurance

Health insurance in the United States is driven by competitive risk rating and is promoted as the best way to give policyholders optimal value for their money and to be fair to those with lower risks. In practice, however, competitive risk rating costs more than noncompetitive, universal systems of health insurance, and it erodes the basic function of insurance to spread infrequent large losses over a wide base. This article describes not only how risk rating covers least those with the greatest medical bills, but also how it has spawned a labyrinth of complex manipulations by insurance companies to charge more or pay less than actuarially fair risk rating would justify. The final section shows that even if risk rating were done fairly, it contradicts moral fairness. Many of the leading proposals for national health insurance do not address these practical and ethical issues. The medical profession and policymakers need to discuss them and take a stand on them.

Inequality and Access to Health Care

Health services research has laid the groundwork for ongoing policy debates over the shortcomings of the American health care system and the need for the expansion of health insurance protection. In the early 1970s, studies of inequality in access to medical care provided the basis for proposals for national health insurance. The examination of the impact of Medicare and Medicaid demonstrated the critical role of these governmental efforts in reducing inequalities in access to care. By the 1980s the focus of investigation turned to the impact of policies designed to contain the cost of health care on access to medical services by vulnerable populations. Documentation of the negative health outcomes that followed from restrictions on access to care has set the stage for a renewed debate over universal health insurance.

An analysis of three national health insurance proposals in Sub‐Saharan Africa

AbstractThe financing and/or provision of health insurance by government has a theoretical basis: it stems from market failure in the private health insurance market; and, from externalities in the consumption of health care by the poor. Government health insurance, or national health insurance (NHI) may be analysed by using five criteria: who are the beneficiaries?; efficiency effects; the equity of financing; the level of administrative costs; and, political acceptability. In the last five years, Ghana, Zimbabwe and Nigeria have each considered proposals for NHI. However, each proposal shows design flaws, when analysed in the light of the five criteria above. This article first considers types of health insurance in Sub‐Saharan Africa, and why NHI, with cost recovery as an essential component, might be desirable. A following section present an outline of the NHI proposals in Ghana, Zimbabwe and Nigeria and points out the design flaws. A final section builds upon the theoretically‐good aspects of the three proposals, and considers some alternate approaches to NHI that these three countries and other countries in the Sub‐Sahara might want to consider.

Health promotion must be incorporated into national health insurance proposals.

Health promotion must be incorporated into national health insurance proposals.

The careful writer and the sound of words.

Editors and scientists are a beleaguered lot, and each group sometimes puts trying, seemingly unreasonable demands on the other. Editors, concerned with the quality of the journal they produce, want clarity and economy in the manuscripts they receive, and scientists, concerned with the quality of their research, want to spend all their time doing it. While the work submitted to the Journal of Community Health is of very high caliber in the second regard, it often falls short in the first; the writing frequently obscures rather than enhances the article. What follows, then, I hope should help us all: a quick refresher course for scientists who want to write well but have little time to improve their skills. Scientific writing generally, and the manuscripts submitted to the Journal of Community Health specifically, have three major problems--structural, logical, and stylistic--which can be systematically isolated and overcome. The structure of the scientific article itself helps create the first problem because of the conventional form such articles must take. The exostructure [Introduction, Materials and Methods, Results, Discussion] makes many writers falsely believe that if they organize their material well, "the paper will virtually write itself."1 The notion is only superficially true, but also appealingly simple, so it encourages authors to organize data neatly into the four-part form while they neglect the discrete nature of each part. An article's separate sections, however, like the whole of an expository essay, paragraph, or sentence, have inherently logical and rhetorical structures that you cannot violate. We may take the following early draft of a paragraph as an example of what happens when you do: This report presents a study conducted by the Section of Public Health and Preventive Medicine. The purpose of this project is to develop an interactive computer-based system for examining the costs of administrating Quality Assurance Systems (QAS) in National Health Insurance (NHI) proposals. The set of equations that makes up this computer system comprises an analytical framework for the examination of the relationships between the distribution of services produced under a given NHI proposal and the various components of a given QAS. The result of this analysis is restricted by the scope of the contract to the administrative costs associated with QAS. Therefore, neither this report nor the computer system developed in this project addresses the issue of the impact of a QAS on the mix of services produced by a given NHI proposal. The focus here is on the relative costs of

Proposal for national health insurance and health policy: social survey results.

Numerous proposals for national health insurance (NHI) are before the Congress. This study measures public preferences for three widely debated forms of NHI bases on national survey data from 1978. Analyses of the comprehensive, catastrophic and deductible forms of NHI are conducted separately using the multivariate probit technique. Findings suggest that, in general, public preference is greatest for the comprehensive plan and lowest for the catastrophic plan. Supporters of the comprehensive plan tend to be young, Democrats, members of lower socioeconomic groups, nonwhite, residents of the West, Northeast or urban areas, and without extended health insurance coverage. Support of NHI options is associated with political party preference as well as sociodemographic characteristics.

Private Health Insurance in a National Health Program: The U.S. Experience

Numerous proposals for national health insurance (NHI) in the United States include a key role for private health insurance agencies (i). This role may be to carry the insurance for persons whose enrollment in private programs is mandated by national law, as in the original socal insurance legislation of Germany in the i88os. (2). Or it may be for the private programs to serve as agents-fiscal intermediaries-for government, as in our current Medicare legislation since 1965 (3). Private insurance programs may even play both of these roles, as in the "National Health Plan" announced by President Carter inJune 1979 (4). Since the proposal of Senator Kennedy, in May 1979, of a complex new approach-the "Health Care for All Americans Plan," this retreat from the original Health Security Bill would now mean that the main labor-sponsored NHI strategy in the United States would also involve private insurance carriers in a central role (s). Because of all these developments, new interest has been aroused i evaluation of the effects of private insurance functons in a statutory national health insurance program. Economists, particularly those with conservative (i.e., "free market") ideologies, tend to examine this queston mainly or solely in tems of the administrative expenses of private versus public management of health insurance. Aside from the subtleties entailed

National Health Insurance Proposals

National Health Insurance Proposals

Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare

I have some bitter disappointments as President, reflected Truman after leaving office, but the one that has troubled me the most in a personal way, has been the failure to defeat organized opposition to a national compulsory health-insurance program. Harry S. Truman versus the Medical Lobby by Monte M. Poen examines proposals for national health insurance from 1914 to 1965 focusing on Truman s efforts during his presidency.

The Impact of the Rhode Island Catastrophic Health Insurance Plan

Under Rhode Island's statewide Catastrophic Health Insurance Plan (CHIP) in effect since January, 1975, and similar to the Long‐Ribicoff National Health Insurance Proposal, Rhode Island pays catastrophic medical expenses over and above a “personal resource payment” (out‐of‐pocket expenses) that varies with income and amount and type of health insurance coverage. Those with qualified plans (plans providing more services) pay less out‐of‐pocket. Benefits accrue mainly to some middle income households. CHIP has increased demand for and prices for health insurance with qualifying coverage, and utilization of medical care. Similar impacts on a larger scale may be expected from any national health insurance program.

Financial Incentives to Perform Medical Procedures and Laboratory Tests

Financial return is one of several factors that may affect a physician's decision to order services for a patient. The extent of financial incentives to perform in-office medical procedures and laboratory tests is illustrated by four hypothetical models of general internal medicine office practice. The model practices consist of fixed ratios of history and physical examinations to return visits, with numbers and types of medical procedures and laboratory tests increasing stepwise through the four models. The procedures and tests included are an electrocardiogram, urinalysis, complete blood count, sigmoidoscopy, tuberculin skin test, two-view chest x-ray, cardiovascular treadmill stress test, and an automated 12-channel blood chemistry test. Charges and office expenses are estimated at 1977 Northern California levels. Net incomes derived for the four models are as follows: $31,000, $55,000; $60,000; and $90,000. The demonstrated financial incentives, which apply not only to internal medicine, but to all fields of medical care, are in conflict with policies that would emphasize personal rather than technical services. National health insurance proposals should include a continuing review of medical services valuation.