Consequences of increased third-party payments for health care services.

The growth of third-party programs to pay the costs of health care has occurred in an unplanned manner. As a result, the country presently is faced with a number of uncoordinated payment programs that sometimes work against each other. While the expansion of health insurance programs has provided the financing necessary to keep our health care system up-to-date, and while such programs doubtlessly have reduced the financial barriers to seeking health care for some population segments, health insurance also has produced some problems. Generally, the contribution of health insurance to these problems is subtle and cannot be quantified. Yet, policymakers increasingly are recognizing that there are factors at work in our health care system that, if continued unabated, will exacerbate the country's health care cost problem. Many of these factors owe their existence to the socially unacceptable incentives provided by most health insurance programs. This article focuses on some of the adverse consequences of health insurance programs and indicates that the future of private health insurance depends upon how these problems are addressed.     

Achieving Equity in Health through Community-based Health Insurance: India's Experience with a Large CBHI Programme

This article analyses equity in enrolment, renewal of enrolment, and utilisation of community-based health insurance with special reference to the Yeshasvini health care programme. The analysis employs a primary survey conducted in rural Karnataka using a random sample of 4109 households. The study identifies quantifiable variables covering various dimensions of vulnerability and assesses their relationship with enrolment, renewal of enrolment, and utilisation using logistic regression techniques. The results demonstrate that inequities do exist even though they are less pronounced in utilisation than in enrolments and renewals. While community-based health insurance (CBHI) may be used as a mechanism to reach the disadvantaged population, they can not be considered as substitute for government-created health infrastructure.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

Health care benefits in the public sector: An examination of availability,size, and managerial effects among north carolina municipalities

This study focuses on the extent to which health care benefits are used in North Carolina municipal governments. As such, it not only maps out the existence of these practices, but also the conditions and circumstances in which they occur. Health care practices (Basic dental and medical coverage, employee assistance programs, and child care provisions) are examined.

Since group health coverage is nearly universal (albeit the type and extent of coverage varies), it was not examined in this survey. With the exception of pre-paid dental insurance (41 percent) and unpaid maternity leave (31 percent), limited use is made of the various health care programs surveyed.

Population and workforce size effects are marginal.The presence of a city manager or town administrator, on the other hand, results in two or three fold the use as occurs in mayor-council cities.     

Managed care systems in the people's republic of china

This article attempts to determine whether or not managed care is the way forward for health services systems reforms in urban China. It first highlights the problems of the present Chinese urban health care financing system, which is largely based on third party fee-for-service reimbursement. It then analyses the salient features of three existing managed care systems in China -private plans, plans under the existing public and labor medical insurance systems, and the newly introduced pilot Employees Medical Insurance Scheme. Available evidence tend to suggest that all of them have been quite effective in controlling cost escalation, and that there have been some improvement in terms of equity under the new Employees Medical Insurance Scheme.     

Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.     

Health care finance in the US: Past,present, and future

Presently the US is the only major industrialized nation that does not insure universal access to health care for all of its citizens. Although the US spends one out of every eight dollars on health care, over one-eighth of all Americans lack basic health insurance coverage. Another concern is health care cost inflation. The quest for comprehensive health care coverage for all Americans began shortly after the turn of the century and has received varying degrees of support since then. Since the historical course of health policy in the US has followed an evolutionary rather than revolutionary course, unless consistent policies are developed to rationalize the incentives facing consumers, providers, and insurers, alike, the future path of American health policy will continue to be characterized by disjointed incrementalism. National health insurance can provide decision makers with a tool to structure and focus the American health care system. In order for cost control measures to be effective they must be coordinated with measures to promote universal access, and vice versa. NHI can be a catalyst to focus attention on the dual goals of access to care and cost containment.     

Health care reform content and process:propositions from the states

Health care reform and cost containment have become central campaign and policy issues in the United States. Although focus now centers on federal health care reform policy, state governments have been actively introducing health care reform legislation. Some of the health care reform initiatives on the state level have influenced deliberations on the federal level and President Clinton's health care reform initiatives will spur further state experimentation regardless of legislative success in Congress, In 1992 nearly all 50 states had either legislation introduced, or special task forces assigned that addressed health care reform issues. This exploratory research compares the content and process of health reform in four states that attempted major reform in 1992—Florida, Washington, Michigan, and Wisconsin—and draws propositions for state reform based on comparisons of content and process. The four states chosen represent geographic diversity and a balance between legislation seeking partial change and legislation calling for universal health care reform. The principal reform bills in each state are compared and assessed on the degree to which they address eight reform elements; high tech medicine, administration, tort reform, long-term care, regulation, insurance mandates, small business insurance, and insurance portability. These initiatives are also compared on a series of reform process variables that relate to the political process for adopting reform: degree of health sector support, type of political strategy used, reform champion, degree of cooperation among policy stakeholders, and timing of initiative. Based on these four cases the phased/partial approach seems to have a greater chance for legislative success than immediate universal reform. Florida's partial, consensus-building approach resulted in the only signed bill of the four states. Washington's bill, which also took a partial approach, passed the state senate before ultimate defeat in 1992 and eventual passage in 1993. Neither of the more ambitious universal health care reform packages introduced in Wisconsin or Michigan got out of committee. Although some of the plans were thorough, none adequately addressed the tradeoff between increasing access to care and containing costs. In addition, this study will demonstrate that universal health care legislation, does not necessarily equate to comprehensive health care reform. The propositions derived from this research have implications for future state health care reform efforts, as well as for federal health care reform policy in terms of the substantive content of reform proposals and the political process by which they are advanced.     

Social Health Insurance and the Use of Formal and Informal Care in Developing Countries: Evidence from Ghana’s National Health Insurance Scheme

This paper studies the relationship between the use of formal and informal health care in a developing country setting by examining the introduction of a social health insurance scheme in Ghana. We estimate the effects of gaining coverage on changes in care seeking behaviour and show how these effects differ by age and wealth status. District-level differences in the implementation of the insurance scheme provide exogenous variation in access to insurance and allow us to address issues with selection into coverage. Results indicate that insurance access strongly increased use of formal care and reduced out-of-pocket expenditures on health services.     

Uneven geographical distribution of medical care: A Ghanaian case study

It is well known that the provision of medical care in developing countries is often very unevenly distributed geographically, and one of the most important points made in Maurice King's pioneering Medical Care in Developing Countries, [1967, Oxford University Press: East Africa] was that health facilities such as hospitals have an extremely small effective geographical range. The purpose of this article is to use new statistical data to analyse the problem of uneven distribution of medical care further, and in this way to investigate the social and cultural factors which are indirectly reponsible. The discussion is in terms of Ghana, but much of it may well have a wider relevance.     

Improving the Health Coverage of the Rural Poor: Does Contracting-Out Mobile Medical Teams Work?

Low population density in rural developing countries coupled with deficient infrastructure, weak state capacity and limited budgets makes increasing health care coverage difficult. Contracting-out mobile medical teams may be a helpful solution in this context. This article examines the impact of a large-scale programme of this type in Guatemala. We document large impacts on immunisation rates for children and prenatal care provider choices. The programme increased substantially the role of physician and nurses at the expense of traditional midwives. The results indicate that mobile medical teams substantially increased coverage of health care services in Guatemala, and could be effective in other developing countries.     

CONSULTATIVE PROCESSES IN HEALTH POLICY IN THE UNITED KINGDOM: A VIEW FROM THE CENTRE

Health policy at national level is the product of a series of continuous and complex interactions between interest groups operating both inside and outside government. It is generally thought that these consultative processes are closed, elitist and dominated by the prestigious medical specialties. Yet there has been a rapid growth in the number of groups representing various interests, professions and care groups. Drawing on recent examples from the national health service, the paper explores the extent to which consultative processes in health policy have remained closed or have been opened up to new influences. The analysis suggests that consultation within the health department is more pluralistic than is usually appreciated. Also, while the closed, elitist mode of consultation with external interests has been eroded marginally, it remains more or less intact. Nevertheless, the ability of powerful medical interests to get their own way to the exclusion of other interests depends on the resources and sanctions available to other groups and on the particular policy issue. It can no longer just be assumed.     

Health strategy and development planning: Lessons from the people's republic of China

In Section I of this paper we present an analytical paradigm by which to evaluate health and medical care services in underdeveloped countries. In Section II, we apply this framework to an analysis of the health policies of one developing country, China. In Section III, we evaluate the Chinese health and medical care policies within the framework of a cost‐benefit analysis and argue that these policies are appropriate to China's factor proportions and health needs. Finally, in Section IV, we raise a number of questions to be considered in any more detailed studies on the transferring of the Chinese services to other developing countries.     

The oregon plan: Toward a model for the future of health care financing

The State of Oregon has proposed a new method of financing health care services for its citizens. Oregon proposes to fund only the most cost-effective services. But in addition to narrowing the offering of health services funded by the State, Oregon proposes to fund all of the State's poor for services, no matter the family status. This broadened number of poor (everyone at the federal poverty level and below, single or married, children or not) will provide health care for more than 200,000 additional Oregonians. The supplementary legislation, SB 534 and SB 935, combined with broadened health care coverage for the poor (SB 27) will cover an additional 478,000 Oregonians. Nearly 95 % of its citizens will have some form of health insurance in Oregon.     

Back to the future: Polish health care reform

In January 1999, the Polish government implemented a new law reorganizing the health care in the country. This paper includes an outline of the changes, the main impact of which consisted of introduction of universal health insurance administered by Health Insurance Funds (“Kasy Chorych”). In June 2001 and 2002, a survey of insurance administrators and health care workers provided data concerning the reception of the new system, the perceived inadequacies, and the postulated changes. The intended objective of privatization of health provisions appears as remote as it was before the changes. The major obstacles are identified as political hurdles, physician resistance, and continued dependence on state allocations.     

Developments in health care finance

Costs, quality, and access are the central themes in health care policy in the United States. In the 1980s the predominate issue is becoming access, and the likelihood for universal health coverage, or a national health insurance program, is growing. This paper explores how the America health care system got to this point and examines the present conditions, the trends, and the consequences of those trends.     

Health care and the elderly.

Western values have long emphasized an interventionist approach to problems of health and health care. Yet, as medical technology becomes increasingly expensive and as the number of older people grows, proposed changes often are now governed more by considerations of cost than by quality of services. This tension between cost and quality also affects public willingness to invest in social components of health care despite their importance in enhancing quality of life. The tension emerges in sharpest contrast as scarce resources are allocated by gatekeepers in health maintenance organizations and in the arrangements for long-term care. With respect to financing, what seems to be needed is a creative mix of voluntary inputs from the community, private initiatives, and new programs of public entitlements. With respect to quality of care, what has often been overlooked is the recognition that gains in the quality of life require programs that encourage older people's continued involvement and participation in social life and in active and healthy life-styles. This article discusses the evolving balance between these two types of interventions: the medical and the social.     

Health care and AIDS

The acquired immune deficiency syndrome (AIDS) is a harbinger for change in health care. There are many powerful forces poised to transform the industrialized health care structure of the twentieth century, and AIDS may act as either a catalyst or an amplifier for these forces. AIDS could, for example, swamp local resources and thereby help trigger national reform in a health care system that has already lost public confidence. AIDS can also hasten the paradigm shift that is occurring throughout health care. Many of the choices society will confront when dealing with AIDS carry implications beyond health care. Information about who has the disease, for example, already pits traditional individual rights against group interests. Future information systems could make discrimination based upon medical records a nightmare for a growing number of individuals. Yet these systems also offer the hope of accelerated progress against not only AIDS but other major health threats as well. The policy choices that will define society's response to AIDS can best be made in the context of a clearly articulated vision of a society that reflects our deepest values.     

Corruption and reforms: A case of Poland's medical sector

This study focuses on the effects of Poland's reforms in the period 1990–2005 on corruption in the health care system. In the last 15 years Poland has transformed its economy drastically, introducing market-oriented reforms into almost every aspect of its economy. In this study we consider how different reforms changed incentives and mechanisms facilitating corruption in the medical care sector. Our conclusion is that corruption in Poland's medical sector has worsened since the onset of the marketization reforms. We support this conclusion primarily by analyzing changes in incentives for corruption and the number of mechanisms facilitating it. In addition, where available, quantitative data are provided, though we recognize that numerical estimates of corruption are subject to substantial error. We focus on three major forms of corruption: patient payments to secure medical treatment or improve its quality, payments from industry (mostly pharmaceutical and medical equipment producers), and the use by physicians of free public facilities for private patients.