Health care financing among the elderly: who really pays the bills?

This paper investigates the issue of who pays the health care bills of the elderly by considering the types of subsidized health insurance protection enjoyed by the noninstitutionalized elderly and the way that increased Medicare cost-sharing efforts in the 1980s are affecting those without additional health insurance subsidies. In making this examination we estimate the out-of-pocket health care expenditures of the elderly either directly or as nonsubsidized medigap premiums by income level, taking into account four types of health insurance subsidies received by elderly persons: Medicare, Medicaid, Veterans Administration health care, and subsidized health insurance from either current or former employers. We find that increased cost sharing is likely to fall most heavily on those elderly least likely to afford it: the poor and near-poor elderly who have only Medicare as a health insurance subsidy, particularly those who are older and sicker and who use Medicare services more heavily. These persons are caught between well-intentioned federal cost-cutting efforts and the often confusing panoply of health insurance programs for the aged, and they will bear an inequitably large portion of any future Medicare cost-sharing initiatives.     

Health care reform in Germany: patchwork change within established governance structures

Under the pressure of health care reform in the 1990s, interactions among the state, sickness funds, and providers in Germany are said to have entered a new era. We examine this new era by assessing both long-term developments connected to German statutory health insurance (SHI) and related short-term developments of the 1990s. Highly institutionalized rules and practices provide little opportunity for abandoning the historical path of two primary factors: the self-governance of SHI and a strong tradition of a semisovereign state. Some opportunities exist for introducing new ideas, rearranging priorities, softening rules, and adding new complex rules and procedures in a fairly fragmented policy-making system, perhaps even because of fragmentation. Yet reforms that depart from the status quo are severely limited by strong legal and administrative traditions and established rules of the game. These restrictions tend to reinforce state intervention, prevent the emergence of consistent and coherent visions of future health policy, and stifle policy innovation and implementation. In sum, reform measures tend to remain well within the priorities established within state and corporatist governance structures.     

Renovating the Commons: Swedish health care reforms in perspective

Recent reform experience in Sweden supports the premise that key dimensions of a country's health care system reflect the core social norms and values held by its citizenry. The fundamental structure of the Swedish health system has remained notably consistent over the past half century, that is, tax-based financing and publicly operated hospitals. Yet on other, nearly as important, parameters, there has been substantial change, for example, the persistent pursuit for thirty years of a stronger primary care framework and the effort to allow patient choice of doctor, health center, and hospital within the publicly operated system. This particular combination of continuity and change has occurred as traditional Swedish values of jamlikhet (equality) and trygghet (security) have been challenged in an environment shaped by an aging population, changing medical technology, and Sweden's integration into the European Single Market. This article explores the ongoing process of health system development in Sweden in the context of the country's broader social and cultural characteristics.     

The form and context of federalism: meanings for health care financing

This article examines the meaning of federalism for health care financing (HCF) and is based on two considerations. First, federal institutions are embedded in their national context and interact with them. The design and performance of HCF policy will be influenced by contexts, the workings of the federal institutions, and the interactions of these institutions with different elements of the context. This article unravels these influences. Second, there is no unique model of federalism, and so we have to specify the particular form to which we refer. The examination of the influence of federalism and its context on HCF policy is facilitated by using a transnational comparative approach, and this article examines four mature federations: the United States, Australia, Canada, and Germany. The relatively poor performance of the U.S. HCF system seems associated with the fact that it operates in a context markedly less benign than those of the other national HCF systems. Heterogeneity of context appears also to have contributed to important differences between the United States and the other countries in the design of HCF policies. An analysis of how federalism works in practice suggests that, while U.S. federalism may be overall less favorable to the development of well-functioning HCF policies, the inferior performance of these policies is to be principally attributed to context.     

Market-oriented health care reforms and policy learning in the Netherlands

In this article we analyze the evolution of market-oriented health care reforms in the Netherlands. We argue that these reforms can be characterized as policy learning within and between competing policy programs. Policy learning denotes the process by which policy makers and stakeholders deliberately adjust the goals, rules, and techniques of a given policy in response to past experiences and new information. We discern three distinctive periods. During the first period (1988-1994), the prevailing corporatist and etatist policy programs were seriously challenged by the proponents of a new market-oriented program. But when it came to political decision making and implementation, the market-oriented program soon lost its impetus because it was technically too complex and could not provide short-term solutions to meet the urgent need for cost containment. During the second period (1994-2000), the etatist program regained its previously dominant position. In parallel to a strengthening of supply and price controls, however, the government also persevered in creating the technical and institutional preconditions for regulated competition. Moreover, public discontent over waiting lists and the call for more autonomy by individual providers and insurers strengthened the alliance in favor of regulated competition. This led to the revival of the market-oriented program in a 2001 reform plan. We conclude that the odds of these new post-2001 reforms succeeding are substantially higher than in the first period due to the technical and institutional adjustments that have taken place in the past decade.     

State Medicaid managed care enrollment: understanding the political calculus that drives Medicaid managed care reforms

The objective of this article is to understand the political motivations underlying Medicaid managed care reforms by examining the determinants of enrollment of beneficiaries in managed care plans in the fifty states. To highlight the role of the model variables, including measures of the political environment, public interest, and special interests, a distinction is made between capitated and fee-for-service managed care enrollment. The results show that cost containment within the context of the Medicaid program is perceived as strongly favored by voters. Accordingly, the relative cost and tax price of providing Medicaid services are important factors in states' decision to enroll Medicaid beneficiaries in managed care plans, particularly capitated ones. The results also indicate a surprisingly significant influence by labor unions that generally oppose managed care enrollment for fears of lost jobs. The recipient population and provider groups also play an important role in shaping the Medicaid managed care landscape. The influence of variables measuring states' ability and willingness to pay and median voter preferences suggest that, within the context of Medicaid managed care enrollment, the public's interests are being served; however, the results also point toward inequities within the program and implications concerning financing arrangements between states and the federal government.     

The Florida Health Care Access Act: a blended regulatory/competitive approach to the indigent health care problem

The problem of indigent health care has received much attention from governmental officials, health care providers, health policy analysts, and others. A majority of states have generated legislative proposals to deal with the problem, although their strategies differ in terms of method and scope. This article discusses Florida's approach to the problem as contained in the Health Care Access Act of 1984 and subsequent legislation. The article will provide background on the reasons a hospital assessment strategy was chosen as the funding mechanism and will examine the problems that occurred during the implementation phase of the legislation.     

Health care of the disadvantaged: the elderly

This paper explores threats to the maintenance and expansion of public commitment to financing health care for the elderly. Threats come from rising costs that increase financial burdens, especially on low-income elderly; efforts to contain costs that may undermine benefits; and financing initiatives that treat the elderly as the sole revenue source for addressing problems in that age group. A review of these threats provides lessons not only for sustaining and improving health care for the elderly, but also for policy toward equally or more disadvantaged groups.     

Report from Germany: current conditions and controversies in the health care system

This paper presents a structured survey of the West German health care and health insurance system, and analyzes major developments of current German health policy. In order to make the analysis more accessible to a largely American audience, brief historical remarks, comparisons with U.S. experience, and considerable data and tabular information are provided. The German statutory health insurance scheme is known as a very comprehensive and generous one. However, under the pressure from rapidly expanding health care expenditures and a severe economic recession, the German governments under Helmut Schmidt and his successor Helmut Kohl imposed a number of cost-containment measures, namely a change in the mode of remuneration for physician services, certain regulations of the drug market, and increased cost-sharing. Cost-sharing is especially favored by the new conservative-liberal government. The article concludes with a summary of striking similarities between the American and German health care schemes, and an outlook on proposals for reform which are currently under investigation by the German government.     

The politics of health care regulation: the case of the National Health Planning and Resources Development Act

This paper examines the political and bureautic dynamics of health regulation under the National Health Planning and Resources Development Act and, to a lesser extent, the Carter Cost Proposal now before Congress. A number of underlying issues that affect the day-to-day exercise of health planning are considered, including the contest between state and local and federal government for program control, jurisdictional conflict between state and local planning agencies, and the unsettled roles to be played by professional planners, consumers, and providers. When we assess regulatory policy in health, these complicating factors must be added to the long list of handicaps that already exist. One important finding is that local planning agencies have embraced the task of health regulation somewhat more fully than had generally been expected. A number of explanations for this are offered. In short, the controlling factors in health planning are political, not technical, and there is more occurring at the state and local levels than many had predicted, although any impact is not likely to be dramatic.     

Health care report cards: implications for vulnerable patient groups and the organizations providing them care

Standardized public reporting on the quality of health care (report cards) offers an opportunity to empower purchasers and consumers so that they can make choices that can result in better health care for less money. However, not all population subgroups are equally well served by the publication of such data. In particular, vulnerable patient groups such as the poor, the less educated, the chronically sick, and members of ethnic or linguistic minorities may find issues of importance to them largely neglected. In addition, the way that report card data are collected, analyzed, and presented may further marginalize the experiences of these groups who in any case are already underserved by the health system. This observation also has important implications for health care providers who serve primarily large numbers of vulnerable patients. The differential impacts of report card data on vulnerable patient groups (and their providers) need to be addressed by researchers and policy makers if access issues are not to be damaged further by the providers' pursuit of quality and value.