Proposed National Health Insurance Research Articles

Consumer-Choice Health Plan

Special Article from The New England Journal of Medicine — Consumer-Choice Health Plan — Inflation and Inequity in Health Care Today: Alternatives for Cost Control and an Analysis of Proposals for National Health Insurance (First of Two Parts)

Mental health and the aging: A review of the literature for clinical social workers

This article is a review of the literature on recent trends in mental health services to the elderly. The focus is on clinical services to elderly living outside of mental hospitals but includes services to residents of community nursing homes and homes for the aged. It is concluded that there is currently a “non-system” of services failing to meet present mental health needs. Current restrictive government reimbursement policies and national health insurance proposals are focused on treatment for acute episodic illness. This orientation does not permit a broader preventive perspective or a comprehensive mental health care approach.

National Health Insurance for mothers and children. Looking at the Javits and Scheuer proposals.

Two bills introduced to the 94th Congress propose a national system of health insurance for mothers and children. These bills provide a new focus for congressional, public, and professional debate about national health insurance, the specific impact of insurance on obstetric and pediatric care, and the merits of using health insurance for mothers and children as a next step on the pathway to universal national health insurance. In this commentary, I will attempt to provide a brief guide to these issues and to the current legislative proposals. Criteria for Judging a National Health Insurance Proposal I believe that there are six basic questions that should be asked in trying to judge a proposal for national health insurance: Does it protect everyone against financial hardship from medical expenses? Does it encourage the utilization of necessary and efficacious services? Does it discourage the utilization of unnecessary or ineffective services?

Proposals for National Health Insurance in the USA: Origins and Evolution, and Some Perceptions for the Future

Reliance upon private and voluntary efforts in health insurance has proved to be inadequate as the promise of medical science has become socially more complex, expensive, and elusive. The real, even if discontinuous, movement toward public and compulsory approaches to national health insurance is accelerating. Any program with reasonable promise of success must achieve both cost controls and systems improvements. Of the proposals before Congress, only one offers assurance that the good in the present system of care will not continue to be an enemy of the better system for the future.

Interfacing national health insurance and income maintenance: why health and welfare reform go together.

The current debate on national health insurance has not given sufficient attention to the impact of various proposals upon income maintenance programs. Health and welfare benefits are difficult to coordinate and frequently work at cross purposes. Health care benefits are one of several in-kind forms of income that can affect the economic behavior and well-being of welfare recipients. As an in-kind form of income, subsidized health insurance for low income persons can undermine the objectives of public assistance, particularly the willingness to work, by making some individuals worse off when income rises. Five national health insurance proposals are analyzed to determine how each will interface with cash transfer programs. Most of these proposals perpetuate many of the benefit coordination problems that now exist with the Medicaid program. The article concludes by delineating some of the difficult policy decisions that must be made if health and welfare reforms are to be meaningful.

The political economy on national health insurance. Policy analysis and political evaluation.

National health insurance (NHI) is discussed as a redistributive issue (that is, conflict over it is characterized by stable coalitions with important ideological differences). Discussion of policy alternatives has been intensified, but obscured, by a rhetoric which insists that the medical care system is in crisis. Both rhetoric and discussion point to three problem areas: cost, quality, and distribution of care. Three kinds of NHI proposals exist--minimal intervention measurees (e.g., AMAs Medicredit proposal), major government action (e.g., Kennedy-Corman), and mixed strategies (e.g., CHIP). While these have different potentials for mitigating the problem areas discussed, none can provide complete solutions. Rather, the goal of NHI is to avert financial catastrophe for families and individuals. The emergence of Democratic majorities in Congress and a Democratic White House increases the chances that some NHI plan will be adopted. Political analysis suggests that, short of aggressive leadership committed to a comprehensive scheme, a "middle ground" solution will be outcome.

Mental health services in the public and private sectors.

Analysis of data on mental health service providers indicates that in 1971 the private sector accounted for 34% of inpatient days, 86% of outpatient visits, 44% of expenditures by source of funds, and 51% of expenditures by receipt of funds. The author believes that mental health professionals must familiarize themselves with the economic interests influencing national health insurance proposals and with public policy making processes if they are to help preserve appropriate roles for the public and private sectors in mental health service delivery.

National health insurance: Some lessons from the Canadian experience

In the current American debate over national health insurance an examination of the Canadian governmental experience is very instructive. Canada is enough like the United States to make the effects of Canadian health insurance policies rather like a large natural experiment. The Canadian experience—universal government health insurance administered by the ten provinces with some fiscal and policy variations—can be used to predict the impact in the United States of proposed national health insurance plans on the medical care system, and the reaction of mass publics and national policymakers to these effects. The central purpose of the Canadian national health insurance was to reduce and hopefully eliminate financial barriers to medical care. In this it succeeded. But it also produced results which Canadian policymakers never anticipated: essentially unexpected side-effects on cost, quality, organization, and manpower distribution of the particular national health insurance program adopted. It should be cause for concern, the article concludes, that most of the prominent American national health insurance proposals resemble the Canadian program in failing to provide a single level of government with both the means and incentives to curb the inflationary effects of national health insurance. The lesson from Canada is that unless the system has very strong anti-inflationary mechanisms and incentives built into it, national health insurance will feed the fires of medical inflation despite great formal governmental authority to control it.

Editorial: Impact of nationwide catastrophic health insurance.

Of the national health-insurance proposals currently before the Congress, most include some coverage for catastrophically expensive illness and several provide catastrophic coverage only. A study recently completed by Arthur D. Little, Incorporated for the Health Resources Administration, United States Department of Health, Education, and Welfare (DHEW), examined the impact on health-care costs and service utilization of a nationwide catastrophic health-insurance program covering persons under the age of 65. The study found that such a program could be expected to have very minor inflationary effects, even without an upper limit on benefits. Benefits under Senator Russell B. Long's Catastrophic Health Insurance . . .

Public and Private Sectors Under National Health Insurance

For more than a decade, health care cost and service issues have been debated energetically in the US Congress and in state legislatures and have been subject to widespread interpretation by the mass media. Various reforms have been proposed, and the concept of a broad, national remedy, in the form of national health insurance, has become increasingly popular. In the past few months, health affairs have moved off the front pages on a routine basis, replaced by headlines about such topics as inflation, food prices, energy shortages, and public morality. With the momentum for national health insurance stayed somewhat, it has been possible to examine health issues both with more reflection and less in a state of crisis. For example, last year's national health insurance proposals are now being reexamined in the cold light of their administrative feasibility and cost, as well as their political appeal. In a less heated

Psychotherapy and National Health Insurance.

Many of the legislative proposals for national health insurance fail to include or severely limit coverage of psychiatric services. The author advances a number of arguments for covering these services, including psychoanalysis, and makes suggestions aimed at a more equitable distribution of psychiatric care under national health insurance.

National Health Insurance Proposals: Their Effect on Family Planning and Other Preventive Health Services

The Nixon Administration Comprehensive Health Insurance Act of 1974 (H.R.12684, S.2970), Kennedy-Griffiths Health Security Act of 1973, (H.R.22, S.3), the Long-Ribicoff-Waggonner Catastrophic Health Insurance and Medical Reform Act (H.R. 14079, S.2513) and the Mills-Kennedy Comprehensive National Health Insurance Act of 1974 (H.R. 13870, 3286) are compared with respect to general concept, coverage of population, benefit structure, financing, cost sharing, administration, provider standards and the effect on existing programs. Family planning services and well-child care are not included in the group of services which are regarded as essential under the Mills-Kennedy or administration proposals. Both bills exempt these services from a general provision which limits coverage to curative care and services. The Long-Ribicoff bill mandates the provision of family planning counseling, services and supplies for the low income population as defined in the bill but limits coverage to other persons to catastrophe-related care. The "model policy" of the bill does not mention family planning or well-child services.

National Health Services: Their Impact on Medical Education and Their Role in Prevention

This book reports a conference that aimed to document the changing pattern of health services and inform conference participants about the health services of other countries. Papers describing health services were presented by knowledgeable representatives from Great Britain, France, Spain, Denmark, Sweden, Norway, Yugoslavia, Israel, India, Japan, New Zealand, and the United States. Health services in the Peoples Republic of China were described by Victor W. Sidel, who had recently visited that country. It would have added greatly to the report if information about medical care programs in the Soviet Union and West Germany could have been included. Speakers from the United States presented five papers that briefly described some of the proposals for national health insurance in this country and discussed the problems and philosophy of the role of government in the provision of medical care and the undergraduate and graduate training of physicians. The paper on National Health

Health and Taxes: An Assessment of the Medical Deduction

A variety of proposals for national health insurance are now receiving serious consideration in the Congress, the Administration, and public discussion. This paper examines the performance of the one national program which provides partial financing of health expenses for all Americans-the medical deduction under the personal income taxusing the Internal Revenue Service statistics on itemized deductions for 1970. Income tax deductions provide this protection in the form of an indirect subsidy to the purchase of health insurance and medical care ser-

National Health Insurance and the Strategy for Change

This paper sounds a note of caution that regardless of the type of national health insurance program Congress will approve from among the proposals now before it, the present defects in the organization of health services in the United States may be strengthened rather than alleviated. Consequently, the reorganization and redistribution of health resources required to secure the availability of care for the greatest possible number may be hindered rather than stimulated. Strategies for change based upon a market and incentives ideology, such as those implicit in the current proposals for national health insurance (as well as those in Health Maintenance Organization proposals), will necessarily be limited in their reorganizational and redistributive effects, inasmuch as they leave untouched the locus of economic and political power in the health sector; it is argued that this very locus of power precipitated the much-quoted medical care crisis. In order to achieve the necessary reorganization and redistribution of resources in the health sector, the author believes that the locus of power must shift from the private to the public sector, permitting the levels of federal, state, and local government to formulate a mechanism for national and regional health planning in which public agencies would be the ones primarily responsible for planning, regulating, and controlling (but not necessarily owning) the distribution of human and physical resources within the health sector. In the light of this recommendation, the present structure for national and regional planning in the United States is described and appraised.

True Catastrophe Medical Expense Insurance

Rising medical care costs combined with rapid advances in medical technology again have brought into sharp focus the problem of catastrophic medical expenses for the public. For those families exposed to medical costs that exceed even the limits of current major medical policies, the result often is financially ruinous. The traditional primary plans by which the public has been protected against catastrophic medical costs, including major medical coverage, have various limitations in meeting this risk. These limitations are explored in the article. Also, the excess medical expense coverage currently written as a part of personal umbrella policies has important weaknesses and very little other health insurance presently is written on an excess basis. Therefore, it is proposed that broad, excess type medical expense coverage be made widely available to the public to enable consumers to protect themselves against potentially catastrophic losses. Various criteria are suggested in the article for such catastrophe coverage, including: (1) no maximum limit, (2) a stop-loss limit on all cost sharing, and (3) broader coverage. The current debate over national health insurance may produce a plan covering catastrophic medical costs under either private or social insurance. The article analyzes the major national health insurance proposals in terms of how they would provide such catastrophe coverage.

Who Gains from Public Health Programs?

Analysis of the economic impacts arising from the introduction of Medicare and Medicaid into federal and state budgets leads one to question the actual magnitude of gains which recipients can expect to obtain from new funding in the health area. A modified cost-benefit analysis of Medicare/ Medicaid income effects on program recipients, non-recipients, and physicians from 1966 to 1968 shows that scarcely 56 per cent of the $14.8 billion spent on the two programs represented gains to recipients. Over the same period, physicians received average net gains of between $5,400 and $7,400 over what would have been the case in the absence of both programs. The implications of these findings apply as much to the several proposals for national health insurance as they do to Medicaid and Medicare. It can be shown that the President's health in surance plan, among others, would result in a similar if not larger unintended allocation of public funds. This raises seri ous questions of equity in the development of national health policy.

The organization and financing of health care: issues and directions for the future.

The various legislative proposals for national health insurance and for reform of the delivery system are discussed in relation to the goal of a workable, rational health care system. The authors suggest the elements of a pluralistic planning and regulatory system, designed to assure comprehensive care to all Americans, as well as criteria for a viable national financing mechanism.

NAS Institute of Medicine: What Role Will It Play?

It is hardly a revelation that the United States has never had a well-defined medical policy, at least compared with the Soviet Union, China and some European countries. True, the Federal Government has taken on increased financing of medical research and development (62 percent of all costs in 1970), so that the Department of Health, Education and Welfare, specifically the National Institutes of Health, has tended to establish some policy. Congress, other parts of the executive branch and the shadowy, but mighty, Office of Management and Budget and varying lobbying groups camping around the Capitol have also had their says on medicine. But whatever national policy there is has been diffuse at best-and loaded far more toward medical research than toward health care. In fact a health care delivery policy has been virtually nonexistent in the United States. This admission comes from no one less than Edward David, science adviser to the President, in an interview with SCIENCE NEWS. Yet such a policy is now necessary in view of the crisis in the delivery of health care: the fragmented, duplicated or inadequate health care facilities; the poor deployment of scarce health care personnel; the high costs of medical services; the lack of a good system of preventive medicine. The problems have special immediacy now that proponents of a welter of national health insurance proposals press for action in Congress. Where is such policy to come from? Congress offers little direction. (A spokesman from a Senator's office admits that someone should sit down and map out a health care delivery system, but his office just hadn't gotten around to it.) Nor does the executive branch. The answer, then, is that health care delivery policy must come from the private sector. Yet neither well-entrenched medical and health organizations, nor a burgeoning health care industry, have provided an excess of inspiration in this direction. Thus the new Institute of Medicine of the National Academy of Sciences headquartered in Washington, raises hopes that it may be the necessary vital force. Its goal is to produce reasoned, balanced and impartial recommendations for developing an American health care delivery policy. Actually the institute was fermenting in the minds of some physicians and scientists four years before the NAS officially agreed to take the institute under its canopy in August 1970. As Walsh McDermott of Cornell Medical College and one of the institute pioneers said, we let every participant ride his own hobbyhorse around the room until it was exhausted. Vested interests then worn out, the institute fathers sat down and drafted a sober and promising charter. It makes the institute an integral, yet semi-autonomous satellite of

National health insurance: what kind and how much. 2.

Abstract Although most proposals for national health insurance meet the criteria of financial accessibility and consumer participation in cost, few measure up to criteria for delivery acceptability, cost efficiency and minimization of governmental regulation. Tax-credit and catastrophic-coverage proposals are deficient in their failure to stimulate strongly changes in the health-delivery system; proposals incorporating a comprehensive health system are deficient for the opposite reason — namely, control over health delivery would probably be centralized to an extent that would preclude consumer choice. Capitation payment for a combination of hospital and physicians' services financed through national health insurance should be achieved for the bulk of the population within a 10-year period, and, in addition, every citizen should be given the freedom to choose from among competing delivery arrangements.