The new Israeli health care reform: an analysis of a national need

This paper describes the current situation of health care services in Israel. Major problems are discussed and analyzed in terms of the dualism of the main health organizations (the Ministry of Health and the General Sickness Fund), the multiplicity and discontinuity of health care delivery, quality-of-care problems, and the uneven geographical distribution of facilities. A proposal for a reform of the health care system is outlined, and its principles enumerated. This reform, suggested by the Ministry of Health, reflects a new approach of separating the direct provision of care from the executive functions of planning and control of services. The Ministry's proposal is analyzed, and its implications are discussed in relation to the American health care system.     

The role of substitutes in policy analysis: acute care services in state Medicaid programs

Using four acute care equations (inpatient, physician, outpatient, and clinic) from a larger model of Medicaid, this research examines the "contents" of policy outcomes. This closer examination of outcomes brings to light the interactions between redistributive programs and services and the role of substitutes and complements in state-level policy analysis. (A substitute is a benefit or service that can be used instead of another to produce a similar outcome; a complement is a benefit or service that is likely to result in the use of another benefit or service.) Support is found for the inclusion of these theoretical constructs in policy analysis. Regarding Medicaid, the author concludes that physician, outpatient, and clinic services all complement hospital services; that physician and outpatient services substitute for one another; that state AFDC and SSI policy decisions have a greater impact on utilization than Medicaid-specific eligibility and service decisions do; and that the factors driving utilization (supply, demand, etc.) vary dramatically across acute care settings. The implications for Medicaid policymaking are also discussed.     

Enrolling children in public insurance: SCHIP, Medicaid, and state implementation

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.     

Policing Medicaid and Medicare managed care: the role of courts and administrative agencies

The much-publicized 2000 case of Frew v. Gilbert, in which a federal judge castigated the State of Texas for deficiencies in its Medicaid program, brought renewed attention to the issue of regulating the quality of care in Medicaid and Medicare HMOs. Frew and other recent cases highlight both the promise and the pitfalls of relying on courts to correct deficiencies in public managed care programs. This article argues that while litigation over inadequacies in Medicare and Medicaid managed care can serve an important signaling function in alerting agencies and legislatures about the need for reform, the role of the courts in policing public managed care is circumscribed by several constraints. Barriers to class action litigation and differences in the institutional capacities of courts and administrative agencies mean that litigation is best viewed as a supplement, not an alternative, to a renewed commitment to strong quality monitoring on the part of Centers for Medicare and Medicaid Services and state Medicaid agencies.     

Missing persons-missing data: the need to collect antemortem dental records of missing persons

The subject of missing persons is of great concern to the community with numerous associated emotional, financial, and health costs. This paper examines the forensic medical issues raised by the delayed identification of individuals classified as "missing" and highlights the importance of including dental data in the investigation of missing persons. Focusing on Australia, the current approaches employed in missing persons investigations are outlined. Of particular significance is the fact that each of the eight Australian states and territories has its own Missing Persons Unit that operates within distinct state and territory legislation. Consequently, there is a lack of uniformity within Australia about the legal and procedural framework within which investigations of missing persons are conducted, and the interaction of that framework with coronial law procedures. One of the main investigative problems in missing persons investigations is the lack of forensic medical, particularly, odontological input. Forensic odontology has been employed in numerous cases in Australia where identity is unknown or uncertain because of remains being skeletonized, incinerated, or partly burnt. The routine employment of the forensic odontologist to assist in missing person inquiries, has however, been ignored. The failure to routinely employ forensic odontology in missing persons inquiries has resulted in numerous delays in identification. Three Australian cases are presented where the investigation of individuals whose identity was uncertain or unknown was prolonged due to the failure to utilize the appropriate (and available) dental resources. In light of the outcomes of these cases, we suggest that a national missing persons dental records database be established for future missing persons investigations. Such a database could be easily managed between a coronial system and a forensic medical institute. In Australia, a national missing persons dental records database could be incorporated into the National Coroners Information System (NCIS) managed, on behalf of Australia's Coroners, by the Victorian Institute of Forensic Medicine. The existence of the NCIS would ensure operational collaboration in the implementation of the system and cost savings to Australian policing agencies involved in missing person inquiries. The implementation of such a database would facilitate timely and efficient reconciliation of clinical and postmortem dental records and have subsequent social and financial benefits.     

Medicaid rationing in Oregon: political wolf in a philosopher's sheepskin

Although the details of the proposal have shifted since it was first described, the Oregon Medicaid waiver has had one consistent feature: it will reduce benefits to AFDC mothers and children who are currently covered by Medicaid in that state, in the hopes of increasing coverage for other individuals who are now uninsured. Because of the adverse consequences for the AFDC population, there should be strong evidence supporting the purported benefits of the proposal before proceeding with the waiver. One of the most intriguing aspects of the waiver proposal is the claim that the money currently being spent on AFDC beneficiaries could be redistributed to expand coverage to a substantial number of the uninsured. The concept is that far more people could receive the most valuable services if those now being served gave up their coverage of the least valuable services. Other purported benefits of the waiver include enhanced citizen participation in decisionmaking, cost-savings, and improved payment levels and delivery arrangements. Remarkably, this analysis of the proposal reveals that the waiver is likely to achieve none of its stated objectives, and instead will have adverse consequences not identified by its proponents. What the proposal would do is to insulate politicians from visible responsibility for limiting benefits for AFDC children and adults. Finally, the proposal undermines 25 years of Medicaid as an entitlement program. As such, it would establish as a social ethic the principle that the poor can be relegated to inadequate care. Such an extreme measure is not justified by the fiscal situation in Oregon, which is not extraordinarily poor or overtaxed, and does not have a particularly generous or unusually expensive Medicaid program.     

Modernizing Medicaid eligibility criteria for children with significant disabilities: moving from a disabling to an enabling paradigm

Children with significant disabilities may qualify for Medicaid benefits, regardless of household income, if their state elects to offer the Tax Equity Fiscal Responsibility Act (TEFRA) option. However, a significant number of children with serious medical problems presently are being denied eligibility for, or terminated from, this Medicaid program. This Article describes the ways in which the existing health insurance system inadequately meets the needs of children with significant disabilities, recounts the history and development of the TEFRA Medicaid coverage option, and analyzes the eligibility criteria used by the various states. It proceeds to consider how disability should be legally defined in the health care context and proposes reforms to modernize the eligibility standards so that these benefits can be more effectively, efficiently, and fairly allocated. To accomplish this goal, the federal statute and regulation that define disability, as well as corresponding state laws, must be reformed so that the law can keep pace with advances in modern medical science, and people with disabilities are not, in effect, penalized for receiving currently accepted preventative care that maintains health but will never cure the underlying disease.     

The potential impact of private long-term care financing options on Medicaid: the next thirty years

This study analyzes the potential effect on the Medicaid program of private sector financing mechanisms for long-term care. The data are from the Brookings-ICF Long-Term Care Financing Model and include projections over the next thirty years. While private financing alternatives have some modest impacts on Medicaid expenditures and the number of Medicaid long-term care recipients, the data suggest relatively little change in the need for Medicaid. There will be substantial increases in Medicaid long-term care expenditures over time, and private sector options cannot change this much.     

Medicare and Medicaid Programs; new payment methodology for routine extended care services provided in a swing-bed hospital--HCFA

The final rule revises the regulations governing the methodology for payment of routine extended care services furnished in a swing-bed hospital. Medicare payment for these services is determined based on the average rate per patient day paid by Medicare for these same services provided in freestanding skilled nursing facilities (SNFs) in the region in which the hospital is located. The reasonable cost for these services is the higher of the reasonable cost rates in effect for the current calendar year or for the previous calendar year. In addition, this final rule revises the regulations concerning the method used to allocate hospital general routine inpatient service costs for purposes of determining payments to swing-bed hospitals. These changes are necessary to conform the regulations to section 1883 of the Social Security Act (the Act), and section 4008(j) of the Omnibus Budget Reconciliation Act of 1990.     

Fostering permanency of children in out-of-home care: psycho-legal aspects

Over the past 20 years increasing interest has been given to children's rights that grant special protections to children living apart from their biological parents. The Adoption Assistance and Child Welfare Act of 1980 was promulgated to prevent unnecessary removal of children from their original families and to ensure permanency when return to their families could not be secured. The psychiatrist's role in this process has been to ensure that effective interventions occur prior to the child being removed from home and that every effort is made to return the child to his or her family of origin once placement has been made. In the event that the child cannot return home, the psychiatrist can assist the court by providing grounds for termination of parental rights and by otherwise ensuring that the child's best interests are protected.