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.     

Reforming New Zealand's health care system

In common with many OECD countries, New Zealand has been engaged in a process of reforming the nation's health care system. In New Zealand's case the reforms have been particularly far reaching and effected within a remarkably short time frame. In 1991 the policy framework was made public, and the legislation to underpin the changes enacted in 1993. Shadow bureaucracies anticipating the reforms were set up as early as 1991, however, thus allowing for the changes to be effected in advance of legislation. Thus in the space of a few years, the social security model of health care, which had been in place for over half a century, was transformed into a system characterised by managed competition. This article begins by briefly describing the social security model of health care, and its inherent problems. I go on to analyze the reforms, focusing on the problems of the previous system that the reforms were intended to address. The major planks of the new system are identified, namely the separation of purchasing of health services from provision and creating a competitive market; the distinction between “personal” and “population” health services; establishment of a core of services to which all citizens are entitled; and the integration and capping of funding for health services, and increasing cost-sharing. Of these policies, only the separation of purchasing and provision of health care and the integration of funding for health services have to date been fully implemented, the remainder having been delayed, modified or abandoned. The health care system has arguably been only partially reformed, therefore.     

Reforming united states' health care system

The US health care system, characterized by high costs and limited health benefits coverage, is constantly undergoing reform. This paper presents a brief overview of the US health care system and its current reform: the use of managed care and medical savings account plans; reducing Medicare and Medicaid spending; and the regulation of managed care system.     

The public valuation of religion in global health governance: spiritual health and the faith factor

ABSTRACT

This article explores how the role of religion is evaluated in global health institutions, focusing on policy debates in the World Health Organization (WHO) and the World Bank. Drawing on Luc Boltanski and Laurent Thévenot’s pragmatist approach to justification, I suggest that religious values are creative and worldly performances. The public value of religion is established through a two-pronged justification process, combining generalizing arguments with particularizing empirical tests. To substantiate the claim that abstraction alone does not suffice to create religious values in global public health, I compare the futile attempts of the 1980s to add ‘spiritual health’ to the WHO’s mandate with the more recent creation of a ‘faith factor’ in public health. While the vague reference to some ‘Factor X’ inhibited the acceptance of spiritual health in the first case, in the second case, ‘compassion’ became a measurable and recognized religious value.     

Generating global health governance through BRICS summitry

While global plurilateral summit institutions (PSIs) of the world's most powerful countries have long generated effective global health governance, the most recent summits of the Group of Eight (G8) and the Group of 20 (G20) have largely abandoned their earlier concern with health, especially outside its specialized food and nutrition link. However, since its start in 2009 in Yekaterinburg, Russia, the annual summit of Brazil, Russia, India, China and now South Africa (BRICS), a new PSI arising has substantially addressed health and started to lead in some ways. The BRICS summit-level health governance has been reinforced by the advent of a BRICS health ministers' forum, other health-related ministerial institutions (notably for agriculture and trade) and official and multi-stakeholder bodies. This article provides the first direct, disciplined empirical analysis of how and why the BRICS summit system has governed global health, based on the models developed for and applied to G8, G20 and United Nations summit governance.     

New federalism and health policy

The making of health policy in the United States is a complex process that involves the private and public sectors, including multiple levels of government. Five characteristics of the policy process are identified, which establish the means by which policies are formulated and which affect the nature of the policies that emerge. These characteristics include (1) the relationship of the government to the private sector; (2) the distribution of authority and responsibility within a federal system of government; (3) the relationship between policy formation and implementation; (4) a pluralistic ideology as the basis of politics; and (5) incrementalism as the strategy for reform. The article focuses on the impact on health policy of the distribution of authority and responsibility within the federal system, particularly the impact of new federalism policies as they emerged during the past decade. The effects of dual federalism, cooperative federalism, creative federalism, and new federalism are examined in relation to health policies. The article concludes with an examination of the challenge to long-established values and health policies posed by new federalism.     

The Russian health crisis and the economy

Russia experienced a severe health crisis in the 1990s, as reflected by a drop in life expectancy. It has been suggested in literature that this poor state of health is likely to endure and will significantly retard economic growth in the country. This paper uses evidence from other former Communist countries and studies of income–health relationship across economies to evaluate these claims. It concludes that the mortality increases of 1988–94 and 1999–2000 were the effects, rather than causes, of the economic recession. The state of health is unlikely to put a brake on future economic growth.     

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.     

The health care state in the information age

The computerization of the medical record has important implications for the governance of health care, and the importance of health care means that changes wrought there are indicative of changes in government as a whole. This paper draws on work in public policy, medical sociology and studies of science and technology, as well as on cross–national empirical research in Britain and France. It describes the recent development of information policy in health care as an exercise in state–building, realized specifically in the governance of the health professions. The paper concludes with a discussion of what is both new and not so new in the form and extent of state power which emerges.     

The joint demand for health care,leisure, and commodities: Implications for health care finance and access in Vietnam

This paper explores linkages between the demand for health care providers and the consumption of food, non-food goods, and leisure in Vietnam, using a mixed continuous/discrete dependent variable model. Cross-price elasticities calculated from the model suggest there are strong substitution effects between health care, leisure, and certain commodities. The model allows us to explore the implications of replacing user fees with alternative forms of health care finance, such as commodity taxes. In particular, the results suggest financing public health care services with a non-food sales tax rather than user fees would be more progressive and would improve access to care.     

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.     

Reform: health care

The Italian National Health Service was established in 1978 as three-tier system, involving State, Regions, USLs (Unità sanitarie locali, Local Health Care Units). The division between the responsibility of determining the general features of health care policy and financing it, on one side (the State), and that of managing services, on the order side (Regions and USLs), was bound to lead to increasing levels of expenditure and large financial deficits. An important reform has been carried out over the last five years, aiming toward a more decentralized system, which, although still public, were based on competition among suppliers and free choice for consumers. We argue that although the reform seems to have been successful in containing public expenditure, it has left some important issues still unresolved: the relationship between patients' freedom of choice and competition among providers, and the definition of a model of rationing the bundle of health services financed by the public sector.     

The aging of the population and health services

The demographic revolution--engendered in large part by modern medicine--which has led to the extraordinary and continuing increase in the number and proportion of elderly persons in the population has profound implications for health services. The elderly are disproportionately heavy utilizers of health care, primarily because of the prevalence of chronic disease. In the United States most health care for the elderly is financed through public funds, and costs have been increasing at an alarming rate. There is wide consensus that, for all the excellence of performance of the medical care system in treating acute episodes, care of chronic disease is frequently unsatisfactory in both quality and cost. Given the demographic imperatives, reform of mechanisms for chronic care is thus essential.     

Top ten health trends

With advances in medicine, science and technology coming fast and furious, today's bold ideas could easily be tomorrow's standard operating procedures. To keep you abreast of developments in medicine, fitness and nutrition, U.S. News has identified the 10 most important health trends for the coming year. From gene therapy to patients' rights, here's a look at what's ahead.     

Multilateral health care negotiations: the shadow at the bargaining table

Third-party payers and state regulatory agencies play a major role in health care negotiations. Third-party payer impact arises because of the significant amount of revenue provided to health institutions by these revenue sources. This article reviews the process by which third-party payers and state regulatory agencies affect health care negotiations and the outcomes experienced under these arrangements. The author describes the multilaterial bargaining structure of health care negotiations and illustrates this relationship through recent hospital bargaining in New York City.     

Competition and health care policy: experience and expectations

Since 1970 federal policymakers have tried to strengthen competition and incentive-based market forces as alternatives to regulation in containing health costs. The effort to stimulate the growth of health maintenance organizations (HMOs) throughout the country has had limited results, and federal plans to promote competition by enacting changes in the health insurance market have so far come to little. Coalitions in some localities have shown growing interest in flexible HMO variants, however, and the intellectual force of the HMO critique of mainstream practices remains strong. Moreover, the federal government has shown new interest in prospective reimbursement of hospitals--a proposal that draws from both HMOs--competition--and hospital rate-setting programs--regulation--the element of prospectivity.     

Establishing a health promoting setting: an experience in an albanian polyclinic

A “health promoting polyclinic” based on the “health promoting setting concept” has been developed in Tirana, the capital of Albania. This paper discusses the implementation and intervention of the project, whereas the final evaluation results will be presented in another article. An important aspect of the whole program is the training of the administrators and staff members in the necessary skills relating to their allocated roles, such as creating a healthy environment, health education, outreach activities and total quality management. In this approach the International Relief Organization (IRO) acting as an external agent took the initiative of enabling, mediating and advocating, as well as providing support for the polyclinic's staff and its clients. The model appears to be effective in promoting health at the secondary health care level (the polyclinic). This may encourage health planners to adopt a similar concept at other settings i.e. general or specialized hospitals.     

A pilot study of the suicide victim's last contact with a health professional

Suicide victims frequently have contact with health care professionals in the months before death. The primary aims of this pilot psychological autopsy study were to determine the feasibility of undertaking a full study and to describe the characteristics of the last health care professional contacts with suicide victims aged > 34 years. We interviewed the informants of 52 suicides. Interviews were obtained from 37 health care professionals who had contact with 28 of the suicides during the 3 months before death. The primary reasons for the last contact with the health care professional were mental health (62%), physical health (22%), and social (14%). 87% of health care professional contacts occurred within 1 month of death. Symptoms of depression were noted in 49% of health care professional contacts. Consensus psychological autopsy diagnoses of depression were made in 64% of suicide victims. Overall suicide risk was assessed by 38% of health care professionals during their last contact. This was more likely to occur when the deceased presented as depressed, was aged < 60 years or seen by a psychiatrist. None was assessed to be suicidal. The family informants regarded nine of the suicide victims to have been suicidal before death but informed a health care professional in only one third of the cases. Critical information that might have altered the management is not often accessed from family members.     

Decentralizing supervision to attain higher productivity: the case of the ecuadorian health system

There is growing interest in developed and developing countries about how to best administer public programs in order to maximize the return on invested resources. This paper examines the extent to which decentralized supervision can help improve health worker productivity. Data on health workers in Ecuador are analyzed. The results suggest that local (or decentralized) supervision is conducive to higher productivity and more hours worked per day by Ecuador's health promoters. The implications for higher health status, and for improving health care in other developing countries are discussed.     

China's provincial diplomacy to Africa: applications to health cooperation

There is a prevailing view of China as a unitary actor in its relationships with African countries. This view is incomplete: on the contrary, China is a collection of provinces, autonomous regions and municipalities with myriad strategic ties to African countries, with decentralization shaping the current form of Chinese government and its level of efficiency. In this paper, factors have been explored for why Chinese provinces have played a role in foreign cooperation in health of African countries, in addition to trade and foreign direct investment. Incentives and disincentives for Chinese provinces to engage internationally in foreign cooperation and health assistance have been identified. The concept of paradiplomacy for health has been presented and this typology has been applied to the example of Chinese medical teams. Finally, we draw linkages between China and other members of Brazil, Russia, India, China, and South Africa.