Defining the road ahead: thinking strategically in the new era of health care reform

Understanding the implications of the new health care reform legislation, including those provisions that do not take effect for several years, will be critical in developing a successful strategic plan under the new environment of health care reform and avoiding unintended consequences of decisions made without the benefit of long-term thinking. Although this article is not a comprehensive assessment of the challenges and opportunities that exist under health care reform, nor a layout of all of the issues, it looks at some of the key areas in order to demonstrate why employers need to identify critical pathways and the associated risks and benefits of each decision. Key health care reform areas include insurance market reforms, grandfather rules, provisions that have the potential to influence the underlying cost of health care, the individual mandate, the employer mandate (including the free-choice voucher program) and the excise tax on high-cost plans.     

U.S. Health‐care Reform: The Patient Protection and Affordable Care Act

This short article provides an overview of the Patient Protection and Affordable Care Act, which was approved by the U.S. Congress and signed by President Barack Obama in March 2010, with an emphasis on provisions related to the expansion of health insurance. It highlights key provisions concerning coverage expansion, insurance market reforms, and the projected costs and financing of the legislation.     

Here it comes: defined contribution health care

The Patient Protection and Affordable Care Act includes provisions to make the individual health insurance marketplace one where all Americans, including those with preexisting health conditions, can obtain affordable coverage. At the same time, the act has failed to address, in any significant way, many of the underlying flaws in the current U.S. health care system that have caused costs to spiral out of control. The combination of persistent U.S. health care cost increases and a viable individual health insurance marketplace will cause a sea change in employer-sponsored health care offerings that is similar to that seen among employer-sponsored retirement benefit plans: movement away from defined benefit approaches and toward defined contribution designs. Although the authors show parallels between the evolution of employers' health care and retirement offerings, they explain why certain key developments will need to occur before defined contribution approaches become as prevalent in employer-sponsored health care plans as they are in today's employer-sponsored retirement plans.     

美国长期护理保障制度改革及其对我国的启示

本文主要运用文献研究法,对美国长期护理保障制度的现状进行了分析。分析发现,当前关国长期护理保障制度存在两大问题,分别是政府财政转移支付缺乏可持续性、私人保单难以覆盖广大中低收入阶层。为解决上述问题,关国政府对长期护理保障制度采取了一系列改革措施,但改革始终没能达到预期效果。美国长期护理保障制度改革启示我们,长期护理保障...     

美国医疗保障制度改革述评

美国是发达国家中唯一没有建立全民社会医疗保障体系的国家。历史上美国曾发起过一次又一次推行全民医保的运动,但结果多以失败而告终。新世纪伊始,特别是金融危机爆发之后,美国民众对医保改革的呼声越来越高。2009年奥巴马就任美国总统后,将其作为施政的重点。美国医改法案几经曲折,最终在2010年3月获得国会批准,正式实施。本文对此次美国医疗保障制度改革的背景、内容及其经济学内涵、改革涉及的争论焦点及未来效果预期等进行深入分析,以期为我国未来医疗保障制度的进一步完善提供借鉴经验。     

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs. This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform. But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following:

• ? In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services.
• ? Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made.
• ? Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component.

As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”     

Health Care Reform,Efficiency of Health Insurers,and Optimal Health Insurance Markets

This research examines the efficiency of the U.S. health insurers. It shows that more insurers are less efficient than in the previous sample year; however, the results suggest that the federal health care reform has no significant effect on the overall efficiency of all insurers as a whole, which is very low but does not change much over time. This research explores how to improve the efficiency of the health insurance market by proposing state, regional, and national efficiency-based goal-oriented market models and an efficiency duplicating system, and it discusses important implications to the health care compacts, the health insurance exchanges or marketplaces, and the national multistate programs. It also analyzes further moves for efficiency enhancement with regard to payment methods and the health care delivery system. One interesting finding is that the Medicaid program is very efficient because it provides support to the offering of Medicaid coverage and further expansion, which enhances the health welfare of society with fewer resources inputs from the perspective of efficiency. This research should provide important insights for state and federal governments, policy makers, regulators, the health insurance industry, and consumers.     

How universal health care would influence decisions about work and retirement

The current U.S. health care system distorts individual decisions about work and retirement. After a brief explanation of how the current health care system works, this article reviews those distortions and considers how individuals would respond to the implementation of a universal health care system. The author argues that the likely adverse impacts of an employer health insurance mandate on low-skilled workers could be more than offset by a well-designed system of government subsidies.     

Stratification, competition and risk distribution: health insurance in Germany and the United States

Issues of unequal risk distribution among sickness funds are given increasing attention in the current discussions on the reform of the statutory health insurance system in Germany. This paper examines the structural determinants of risk distribution and points toward the links between social stratification, competition, health risk and insurance status. A model showing the links between basic structural determinants is presented. Using health survey data from Germany and the U.S., statistical analyses are conducted. The results support the model and indicate its applicability for both health care systems. The paper concludes by indicating the relevance of such findings for health policy and future research.     

Managed Care and Health Care Utilization: Specification of Bivariate Models Using Copulas

This article studies the effect of managed care on health care utilization compared to traditional fee-for-service plans in private health insurance market. To construct our hypothesis, we build a game-theoretic model to study health care utilization under a two-sided moral hazard: of patients and providers. In econometric modeling, we employ a copula regression to jointly examine individuals’ health plan choice and their utilization of medical care services, because of the endogeneity of insurance choice. The dependence parameter in the copula reflects the relation between the two outcomes, based on which the average treatment effects are further derived. We apply the methodology to a survey data set of the U.S. population and consider three types of curative care and three types of preventive care for the measurement of medical care utilization. We find that managed care is in general associated with higher care utilization. Evidence is also found on the underlying incentives of both patients and medical providers.     

A case of constitutional apples and oranges: a functional comparison of pension priority and benefit guarantees in U.S., U.K. and Canadian insolvency and pension law regimes

Canada's insolvency law reform increased the priority granted to employer‐sponsored pension claims. The article compares the treatment of such claims in the U.S., the U.K. and Canada. A comparison of the legislative provisions concerning pension funding shortfalls from contribution arrears or economic underperformance in relation to the assumptions used for investment income or liability valuations finds that insolvency law has been used to address contribution arrears, but risks from economic underperformance have been addressed by pension benefit insurance. Post‐insolvency priority for contribution arrears provides appropriate incentives to discourage pre‐insolvency preferences for payments to other creditors, while shortfalls from economic underperformance do not involve issues of preference between creditors. The absence of any insolvency rationale for changing priority for shortfalls from economic underperformance and the likely disparity between the assets available to satisfy clams and the much larger amounts of such shortfalls makes the use of insolvency law to address this risk much less effective than insurance. Canada, however, has not adopted the insurance policy instrument used in the U.S. and U.K. to mitigate the impact of pension funding shortfalls. The constitutional inability of Canada to legislate in respect of matters of pension regulation that would allow it to control the well‐known insurance problems of moral hazard and adverse selection may explain why it has only chosen to adopt an insolvency policy instrument. However, a change in priorities in insolvency may generate incentives for secured creditors that either undermine or reinforce this policy choice. Secured creditors could attempt to circumvent the new priority scheme through private arrangements with the debtor or to increase their monitoring activities to ensure the debtor is current in its pension contributions. Secured creditors choices will be influenced by the bankruptcy courts' interpretation of the preference provisions in the insolvency legislation. Copyright © 2009 John Wiley & Sons, Ltd.     

The effect of industry consolidation and deposit insurance reform on the resiliency of the U.S. bank insurance fund

We examine the effects of structural change in the U.S. banking industry, as well as key regulatory changes, including recently enacted deposit insurance reform legislation, on the resiliency of the FDIC-administered bank insurance fund (BIF) by estimating and comparing the probability of BIF insolvency over time. We do this using a Markov-switching model that relies on historical patterns of BIF disbursements to define the probability of switching among three “states” of the banking industry's financial health. Monte Carlo simulations are then performed to project the financial condition of the BIF over a 50-year period. Our results indicate that the insolvency risk to the bank insurance fund has increased significantly due to industry consolidation, and is mainly due to the concentration of deposits in the 10 largest U.S. banking companies. We also find that recent deposit insurance reforms will cause only a marginal reduction in the risk of BIF insolvency. The increased risk associated with a more concentrated industry structure simply dominates the reform effect.     

医保制度改革：从城镇保障到城乡统筹——医疗保障“马鞍山模式”研究

安徽省马鞍山市医疗保险制度改革,一直以其创新性和样本性被各级政府、媒体及公众广为关注,被称为“医疗保险马鞍山模式”。本文通过对马鞍山医保制度改革从城镇保障发展到城乡统筹过程的调查,介绍该市医疗保险制度的发展历程,总结、分析统筹城乡医保制度的主要内容、特点及成效,探究存在问题及对策,以期为研究中国当前的医疗保险制度改革提供参考,为广大中西部地区中小型城市的医疗保险工作提供借鉴。     

城镇职工退休人员缴纳医疗保险费的可行性及其相关问题探讨——社会保障学者专题讨论综述

2016年初有政府官员提出要建立合理分担、可持续的医保筹资机制,合理强化医保个人缴费责任,研究实行职工医保退休人员缴费政策。部分社会保障学者在微信平台上进行了"退休人员缴纳医疗保险费是否缓解医疗基金支付压力的良方"专题讨论。讨论从退休人员缴纳医保费问题的可行性开始,逐渐深入到医疗控费、公立医院改革、政府角色定位和长期护理保险等医疗领域重难点问题。     

Determinants of No-Fault Insurance Measures

In spite of being touted as the panacea for rising premiums and unfair settlements, no‐fault automobile insurance provisions exist in fewer than one third of U.S. states. Few researchers have examined why such measures exist in some states but not in others. This article focuses directly on this issue by looking at the factors that help explain the type of no‐fault regime in place. The article conducts an empirical analysis using a data set that spans all 50 states over the 19‐year period from 1972 to 1990. Among other things, the analysis finds that the structure of the insurance industry and the type of rate regulation under which it operates are determinants of these decisions.     

论商业健康保险在新医疗保障体系中的地位

国务院新公布的《关于深化医药卫生体制改革的意见(征求意见稿)》引发了社会各界的高度关注,方案中明确提出在新的医疗保障制度构建中要积极发展商业健康保险。国际经验表明,要建立一个高效率运行和可持续发展的医疗保障体系,商业健康保险是不可或缺的重要组成部分。本文从经济学理论和医疗保障的实践结果两个角度出发,论述商业健康保险与社会医疗保险合理配合的必要性,以及商业健康保险在医疗保障体系中的优势和特殊作用,并对进一步确保我国商业健康保险发展提出相应的政策建议。     

Die Diskussion über die Portabilität von risikogerechten Transferbeträgen in der Privaten Krankenversicherung

The capital funded health insurance system in Germany (the PKV) is afflicted with a lack of competition because insurants loose their ageing provisions if they switch their insurer. This leads to prohibitive switching costs even after few years of insurance. An intensified competition can only be achieved by transferring ageing provisions with the switch-over. But this raises complex economic and actuarial questions.The article starts with a motivation of the appropriateness of calculative ageing provisions. These quantities can be transferred. A further amount has to be transferred in order to avoid risk selection. Central requests for a mechanism to determine such risk adjustment amounts are derived. After that, options for an implementation are lined out.     

美国社会保障制度改革建议与反思

改革社会保障制度并恢复其财务平衡是21世纪美国最重要的公共政策问题之一。为此,美国的政策制定者和学者展开了一场关于社会保障制度改革的激烈争论,并提出了广泛的改革建议。本文在介绍了美国社会保障制度的长期赤字规模之后,分析了造成制度长期赤字的根源,然后重点梳理了2000年以来主要的改革建议,最后通过反思美国社会保障改革的争论得出了几点启示,希冀有助于中国养老社会保险制度的完善和发展。     

Manufacturing firms' decisions regarding retiree health insurance

The trend for employers to discontinue offering retiree health insurance has profound implications for a large and growing share of the U.S. older population. The authors explore factors related to the firm's decision to offer and contribute to retiree health insurance using data from manufacturing firms. Their findings indicate that while firm characteristics, such as size and age, affect the probability that a firm offers retiree health insurance, employer contributions to this benefit are significantly related to the firm's financial performance and the alternative insurance options available in the market. The article concludes with a brief discussion of policy-related measures with potentially important implications for the future of retiree health benefits.     

What can Canada teach us about health care financing?

Canada now spends proportionally more on health care than any other country except the U.S., Sweden and the Netherlands - about 7.2% of its GNP or about $500 per capita. Almost all Canadians (99%) are insured against the cost of all hospital and physician expenses through government health insurance programs administered by the provinces. Hospitals are reimbursed by the government 26 times per year and must work within annual budgets formulated by the Ministry of Health. The fiscal restraints imposed upon hospitals have caused them to look at expansion of shared services, regionalization and a slowed rate of growth. As in the U.S., hospital administrators complain about government regulation on the grounds that individual physicians have a much greater influence over utilization than do hospital administrators. Further hospital cutbacks will have the effect of reducing services and therefore, costs. However, there is concern that these kinds of modifications will result in services among communities which would affect the very principle of universal health insurance for Canadians.