The Health Insurance Reform Debate

This article provides an overview of the U.S. health care reform debate and legislation, with a focus on health insurance. Following a synopsis of the main problems that confront U.S. health care and insurance, it outlines the health care reform bills in the U.S. House and Senate as of early December 2009, including the key provisions for expanding and regulating health insurance, and projections of the proposals' costs, funding, and impact on the number of people with insurance. The article then discusses (1) the potential effects of the mandate that individuals have health insurance in conjunction with proposed premium subsidies and health insurance underwriting and rating restrictions, (2) the proposed creation of a public health insurance plan and/or nonprofit cooperatives, and (3) provisions that would modify permissible grounds for health policy rescission and repeal the limited antitrust exemption for health and medical liability insurance. It concludes by contrasting the reform bills with market-oriented proposals and with brief perspective on future developments.     

美国医疗保险扩面改革之路的里程碑

虽然美国有两大类三大层次的医疗保险体系,但没有实现如其他大多数发达国家那样的全民医保,缺乏一张覆盖全国的社会医疗网络,始终是美国近10年来备受诟病的社会问题.没有医疗保险的问题始终处于社会政策争议的前沿和核心.之前克林顿总统失败的改革方案核心就是实现全民医保,15年后,奥巴马新医改方案又明确将扩大覆盖面作为其改革的重中之重.然而,历经波折得以通过的奥巴马医改法案却依然面临诸多反对和抗议,其中最为核心的是关乎强制参险的条款.2012年6月28日,美国最高法院裁定奥巴马医疗保险改革的大部分条款合乎宪法,最具争议的强制参险也得以保留,这意味着美国在实现全民医保时代的进程中向前迈出了一大步.     

Prospects for account-based health plans under the Patient Protection and Affordable Care Act

Account-based health plans (ABHPs), which combine high-deductible plans with either health reimbursement arrangements (HRAs) or health savings accounts (HSAs), have gained popularity in recent years. Because there is growing evidence these plans are indeed engaging consumers and moderating cost increases, employers will need ABHP design options as they strive to bring costs under control in coming years. Some observers, however, are now concerned that benefits standards introduced by federal health care reform will undermine these plans, and many in the business community anticipate new health benefits mandates will drive up employers' total health care costs. The authors show that although the Patient Protection and Affordable Care Act (PPACA) of 2010 includes numerous provisions that will likely increase costs for employers, the law also accommodates, and may even foster, HSAs and HRAs.     

内蒙古医药卫生体制改革惠民效应分析

深化医药卫生体制改革是党中央、国务院推行的一项重大惠民工程,也是内蒙古自治区区委、区政府确定的惠民实事之一.新医改固然千头万绪,但评价和衡量其成效的关键在于百姓得实惠.本文正是抓住这一突破口,来了解内蒙古自治区新医改阶段性进展,初步评估医改所取得的效果,分析和研究改革实施过程中出现的新情况和影响因素,为相关部门完善政策措施提供依据和信息支持.     

政府卫生支出的差异性评估:基于省际、区域和城乡的实证研究

本文聚焦政府卫生支出的差异性,运用基尼系数、泰勒指数等方法,定量研究省际、区域间和城乡间政府卫生支出的不均衡状况和程度,研究发现,经济发展水平决定了各地政府卫生支出的水平和居民医疗卫生服务的水平.医疗卫生资源的配置不当和制度缺陷是造成目前政府卫生支出不均衡的主要原因.在新医改的背景下,调整发展思路,完善相关制度有助于改善政府卫生支出不均衡的状况.但是,制度的惯性和体制的约束决定了不均衡状况的改变将是一项长期的工作.     

医保支付之限额付费方式——基于湖南蓝山、桑植两县的调查

医疗保险支付方式是医疗保险机构对医、患(参保人)的付费方式。支付方式改革是当今世界很多国家医改的核心与难题。湖南蓝山县和桑植县推行了限额付费方式改革,参合农民在乡镇卫生院看病就医,门诊、住院费用付费限额内如实自付,超额部分由新农合基金全额报销,同时,对卫生院实行诊疗人次费用、住院床日费用以及总费用控制,对医生实行绩效工资制。创造了有别于"全民免费医疗"的"全民限费医疗"新模式。推广这种新模式的路径是:明确医疗服务的享受主体、服务主体及范围,科学制定总额预付标准,完善监管机制,建立医疗服务与社会医疗保险二位一体的新体制等。     

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.     

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.     

试析医疗卫生事业发展的特殊矛盾和我国医改的路径选择

市场经济条件下医疗卫生事业发展面临五大特殊矛盾。现行医疗卫生体制要解决的首要问题是体制、机制创新问题。公立医院改革和医疗保险体制改革相结合,建立以公益性医院为主题的医疗保险职能和公共医疗服务职能相结合的制度统一、全民覆盖、统筹城乡的新型公共医疗服务保险制度,构建政事分开、管办分开、医保基金管用分开的医疗卫生管理体制,是化解现行医药卫生体制蕴藏的内在矛盾,破解我国医改难题的可行的路径选择。     

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。     

The impact of health reform on HSAs

The health care reform law contains only two direct changes to health savings accounts (HSAs): eliminating the ability to use the HSA for over-the-counter drugs and increasing the early withdrawal penalty from 10% to 20%. The indirect changes, however, could drastically curtail the growth of HSAs or even result in the end of HSAs. The actual impact is uncertain at this time because much of the detail of the law is left to regulatory interpretation. This article identifies and analyzes seven areas in the new law that could indirectly impact HSAs.     

Personal Reflections on Ten Years of the IASB

The International Accounting Standard Board's first 10 years were, in many ways, tumultuous. Established initially as a type of accounting ‘think tank’ with a mandate to develop high‐quality accounting standards that could be adopted on a voluntary basis by countries around the world, it soon gained an international constituency that thrust it into the hurly burly of international accounting standard setting. Before it knew it, the Board was faced with not only resolving challenging technical issues but also dealing with the politics and other pressures that accompany attempts to change accounting practices in highly controversial areas. This article is a personal reflection on the Board's journey from its inception in 2001 until 2011, when the last of the initial board appointees, including the author, retired from the Board. The article indentifies and discusses some of the critical events that took place, including the impact of some of the events on the people directly involved.     

Employer Health Insurance Mandates and the Risk of Unemployment

Employer health insurance mandates form the basis of many health care reform proposals. Proponents make the case that they will increase insurance, while opponents raise the concern that low-wage workers will see offsetting reductions in their wages and that in the presence of minimum wage laws some of the lowest wage workers will become unemployed. We construct an estimate of the number of workers whose wages are so close to the minimum wage that they cannot be lowered to absorb the cost of health insurance, using detailed data on wages, health insurance, and demographics from the Current Population Survey (CPS). We find that 33 percent of uninsured workers earn within $3 of the minimum wage, putting them at risk of unemployment if their employers were required to offer insurance. Assuming an elasticity of employment with respect to minimum wage increase of -0.10, we estimate that 0.2 percent of all full-time workers and 1.4 percent of uninsured full-time workers would lose their jobs because of a health insurance mandate. Workers who would lose their jobs are disproportionately likely to be high school dropouts, minority, and female. This risk of unemployment should be a crucial component in the evaluation of both the effectiveness and distributional implications of these policies relative to alternatives such as tax credits, Medicaid expansions, and individual mandates, and their broader effects on the well-being of low-wage workers.     

A sense of urgency: state governments and health care in the 1990s

Unless President Clinton induces Congress to move exceedingly quickly to roll Medicaid into some larger reform scheme, his administration will be under heavy pressure to free states to pursue their own health care reform agendas. At that juncture, the most likely casualty would be the ERISA preemption.     

Global trade and the future of national health care reform

As a result of economic globalization, health care reform is no longer strictly a matter of domestic health policy and politics. This paper argues that international trade agreements impose institutional constraints on governments’ abilities to implement health care reform, and, if left unchallenged, could frustrate social reforms. The thesis is developed through three case studies that examine the implications of various trade agreements for health care reform in the United States, Canada, and Australia. The findings are discussed in the context of theoretical debates concerning the impact of globalization on the autonomy of nation states and the relevance of national politics.     

Company Law Reform and the Board of Trade, 1929–1943

The accounting provisions of the Companies Act 1929 were very permissive. Through the 1930s and early 1940s a substantial volume of criticism was directed at these provisions and an active campaign for their reform was waged. Reform was only forthcoming, however, after 1945 under the influence of the report of the Cohen Company Law Amendment Committee. The government department responsible for managing the reform was the Board of Trade. The records of the Board of Trade reveal that through the 1930s there had been several internal inquiries into the need for reform of the law relating to accounting. None of these had led to any change. In late 1942, however, the Board of Trade initiated an inquiry into company law reform and a major part of the explanation for this initiative appears to lie in the change in attitudes towards the social obligations of companies that had been stimulated by the Second World War.     

The consumer-driven approach: can it pick up where managed care left off?

Managed care has failed and health care costs are once again out of control. Given the current political, social and economic environment, there are now two options: a single-payer health care system, or an aggressive and global employer health benefits redesign that strongly encourages consumer-driven behavior. This article discusses the failure of managed care and ways that employers can promote consumer-driven behavior now using available tools and plan provisions.     

Comprehensive state health reform initiatives

Policy makers, consumers, providers and purchasers of health care will do well to pay close attention to the many comprehensive health care reform initiatives under consideration by state legislatures.     

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。     

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.”