Obstacles to dependent health care access in Oregon: health insurance or health care?

In the 1980s, Oregon was one of a handful of "states that could not wait" for national health care reform. Oregon's chosen approach to reform was predicated on two widely accepted assumptions. First, universal access to health care is best achieved by universal access to health insurance. Second, universal access to health care could best be achieved, at least politically, by incrementally building upon the existing health care delivery and insurance system. This article questions both of these assumptions in light of Oregon's decade-long experience in trying to expand access to health care among its dependent population.     

What is the goal of access to health care?

This article first examines the justifications for the goal of access to health care and the variations between health systems in their endorsement of individuals' rights to health care irrespective of income, ethnicity, age and other characteristics. It then examines the meanings of the goal of "access" to health care and considers four key dimensions--service availability ("having" access), service utilisation ("gaining" access), the relevance and effectiveness of services and equity of access. These dimensions provide a common framework that can be applied across countries and health systems and employed to assess the extent to which access to health care is actually achieved.     

Intimate partner violence research in the health care setting: what are appropriate and feasible methodological standards?

The past 20 years of research has exposed the profound cost of intimate partner violence (IPV) in health care problems and health care dollars for victims and bystanders. As a result, professional organizations encourage clinicians to identify IPV victims and to refer them to community resources. To date there is little evidence to show the value of these efforts, and many completed studies are criticized for methodological weaknesses. IPV studies are challenging to design, and the double-blind randomized controlled trial may be an impossible standard. To move forward, funders and study committees are encouraged to reassess the standards for IPV research methodologies.     

The fundamental law that shapes the United States health care system: is universal health care realistic within the established paradigm?

In this article, the author draws from his own experience as a doctor in describing the issues the uninsured patient population faces. Pointing out that neither the U.S. Constitution nor case law provides a positive right to health care, the author describes the parameters of federal health care funding and ultimately concludes that universal health care cannot be fully achieved in the U.S.     

Aligning physician decision-making with the goals of health care organizations: are there any lessons from law firms?

In order to achieve efficiency in the delivery of health care services, it is essential to align more closely the behavior of physicians with the goals of the health care organization with which they are affiliated. Achieving alignment presents a number of challenges, including legal constraints, a long tradition of physician independence, a tendency for physicians to become involved in procurement decisions, and a scarcity of comparative effectiveness data that could serve as a basis for treatment protocols and purchasing decisions. The article discusses these challenges and suggests some partial solutions. In addition, it compares the incentives that affect physicians in health care organizations and partners in law firms and suggests that there may be some lessons that health care organizations can learn from the firms.     

Moral hazard in health insurance: are consumer-directed plans the answer?

The concept of moral hazard in relation to health insurance is an area that has both haunted and fascinated economists, policy-makers, and payers almost since the first health insurance plans were offered by employers. Through the years since Kenneth Arrow's groundbreaking work in 1963, the health care industry has been looking for the proper level of cost-share for patient insureds that will affect their health care choices. The approach of some newer plan offerings, termed 'consumer-directed' or 'consumer-driven' plans by their promoters, seem to have the potential of affecting moral hazard in health insurance.