Confronting the fear factor: the coverage/access disparity in universal health care

Since their introduction following World War II, single-payer health care systems and universally mandated health care systems have stumbled, but in their pratfalls are many lessons that apply to the universal health care proposals currently on the table in the United States. The critical and often-over-looked point is that universal coverage does not guarantee that individuals will receive needed care--In many cases guaranteed access to care is a false promise or available only on a delayed timetable. A more feasible alternative lies in providing a safety net for citizens who truly need care and financial support with an appropriate system of checks and balances--without disrupting the economic and actuarial fundamental principles of supply and demand and risk classification.     

Finding a lasting cure for U.S. health care

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.     

论人人享有基本卫生保健之改革

本文通过分析"看病贵、看病难"原因而导致的阻碍人人享有初级卫生保健的主要因素,提出必须深化卫生体制改革,发展基层社区卫生服务、建立覆盖全民的基本医疗保障制度以及实行均等化的公共卫生服务和基本药物制度,以实现人人享有初级卫生保健的目标。     

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.     

New post‐ACA insurance data highlights health insurer spending on health care quality

Following the Patient Protection and Affordable Care Act (ACA), annual financial reports by commercial health insurers include more detailed information on a Supplemental Health Care Exhibit. In this new exhibit, insurers illustrate spending on the provision of medical services and associated expenses. These expenses, which were commonly reported as “claims adjustment” and “general administrative” expenses, can now be allocated to several new categories of expenses associated with combatting fraud and improving patient health care quality. This article illustrates that quality improvement expenses have increased significantly in the individual, small group, and large group markets following implementation of the ACA. Of the five types of quality expenses reported, the greatest proportion of spending has been toward the improvement of health outcomes and the most pronounced increase from 2011 to 2017 has been spending toward increased wellness and health promotion activities, which include activities such as wellness assessments and coaching programs for patients with chronic diseases. Given that the ACA was designed not only to broaden access to health insurance but also to improve health, analysis of the allocations to various types of quality improvement activities highlights the private market's contribution to improving the health of the US population.     

Consumerism and wellness: rising tide, falling cost

Annual employer-sponsored health plan cost increases have been slowing incrementally due to slowing health care utilization--a phenomenon very likely tied to the proliferation of health management activities, wellness programs and other consumerism strategies. This article describes the sharp rise in recent years of consumer-directed health plans (CDHPs) and explains what developments must happen for genuine consumer-directed health care to realize its full potential. These developments include gathering transparent health care information, increasing consumer demand for that information and creating truly intuitive data solutions that allow consumers to easily access information in order to make better health care decisions.     

Culture, infrastructure and international health benefits delivery

When selecting a health insurance carrier for international employees, it is advantageous to recognize that valid assumptions made when selecting domestic benefits simply do not apply in the international realm and can lead to costly errors. This article examines some scenarios and cultural anomalies that invalidate commonly accepted domestic health insurance practices. It explores strategies for simplifying benefit design, providing access to quality care abroad, assessing costs, minimizing overseas risks and understanding the cultural impact on health care delivery.     

The future of therapeutics in the north

Health-care systems occupy from 6% up to 15% of developed countries' GDPs. Therapeutics, particularly hospital care, occupy the bulk of these expenditures, despite their focus on dealing with disease after it arises. In the 21st century health-care systems will focus on health gains. Therapeutics will have broadened to encompass prevention and treatment, and will be focused on each individual's unique biological, psychological and social needs. Major killers, most particularly heart disease and cancer, will be far more preventable or curable, because of changes in therapeutic paradigms to more holistic approaches as well as important biomedical breakthroughs. There are a variety of negative possibilities, including continued preeminence of the medical model, growing costs, increased inequality in access, and greater poverty and social disintegration. The movement to therapeutics more focused on health gains will be accelerated by a variety of trends, particularly the development by communities in the USA and many other countries of shared visions that guide the evolution of health care in these directions.     

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.”     

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 SEARCH FOR A PROPORTIONATE CARE LAW BY FORMULA FUNDING IN THE ENGLISH NHS

Although the National Health Service was created to achieve equity of access to health care in 1948, over twenty years later an 'inverse care law' was seen to operate. The 1976  Report of the Resource Allocation Working Party  laid the principles of formula funding to achieve an equitable distribution of resources, to move, over time, towards the operation of a proportionate care law. These principles have been applied ever since in England. This paper describes the context, governance and subsequent development of formulas and three persistent problems: accounting for populations, their needs and variations in the unavoidable costs of providers. The paper concludes by outlining continuing problems from the past and new challenges of formula funding in England to reduce 'avoidable' inequalities in health.     

Universal basic benefits preempt mandated benefits

Many states seek to expand health care access to uninsured people. As part of their efforts, states must define a basic level of health services to which all residents would have access. Presumably, this level of services would be leaner than that now covered by most health care policies. As it is, private insurers are already mandated by all states to include certain benefits, which differ widely from state to state. However, simple fairness argues that once a state defines a basic level of health services, that level should function as a floor for everyone and replace the previously mandated benefits (which, nonetheless, may be a useful guide in defining a basic level of health services).     

Redefining competition in health care

The U.S. health care system is in bad shape. Medical services are restricted or rationed, many patients receive poor care, and high rates of preventable medical error persist. There are wide and inexplicable differences in costs and quality among providers and across geographic areas. In well-functioning competitive markets--think computers, mobile communications, and banking--these outcomes would be inconceivable. In health care, these results are intolerable, with life and quality of life at stake. Competition in health care needs to change, say the authors. It currently operates at the wrong level. Payers, health plans, providers, physicians, and others in the system wrangle over the wrong things, in the wrong locations, and at the wrong times. System participants divide value instead of creating it. (And in some instances, they destroy it.) They shift costs onto one another, restrict access to care, stifle innovation, and hoard information--all without truly benefiting patients. This form of zero-sum competition must end, the authors argue, and must be replaced by competition at the level of preventing, diagnosing, and treating individual conditions and diseases. Among the authors' well-researched recommendations for reform: Standardized information about individual diseases and treatments should be collected and disseminated widely so patients can make informed choices about their care. Payers, providers, and health plans should establish transparent billing and pricing mechanisms to reduce cost shifting, confusion, pricing discrimination, and other inefficiencies in the system. And health care providers should be experts in certain conditions and treatments rather than try to be all things to all people. U.S. employers can also play a big role in reform by changing how they manage their health benefits.     

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。     

From Plan to Market: A Comparison of Health and Old Age Care Policies in the UK and Sweden

This article reviews changes in the organization, delivery and financing of health care and old age services in the UK and Sweden over the past 25 years. User autonomy has become a more important policy objective than equity of access or equality of opportunity, with a greater reliance on market mechanisms for delivering services. The public and politicians seem to be prepared to accept that competition, choice and decentralization may result in a widening of regional and geographical inequalities, and the erosion of the universal character of the welfare state. These developments reflect broader normative shifts in both societies, and are likely to continue and become more widespread in the future, as they will be strongly influenced by demographic and social factors, fiscal constraints and the policies of supranational bodies such as the European Union.     

HOUSEHOLD RESPONSES TO PUBLIC HEALTH SERVICES: COST AND QUALITY TRADEOFFS

The effectiveness of government investments in health care dependson the public's response to price and quality as well as onwhether these expenditures actually improve health outcomes.Consumers, even those in low-income households, are willingto pay fees for better health care if the fees translate intoimproved access and reliability. But when prices rise withouta concomitant improvement in services, malnutrition and childmortality rates increase. The availability of basic health carehas a relatively greater impact on households with low incomesor low education, or both, than does the provision of more specializedservices. This article describes the types of services for whichhouseholds indicate they are willing to pay increased fees.It also indicates the potential gains from improving these services,as well as the consequences of moving faster on cost recoverythan on providing improved or better-targeted services.      

From Plan to Market: A Comparison of Health and Old Age Care Policies in the UK and Sweden

This article reviews changes in the organization, delivery and financing of health care and old age services in the UK and Sweden over the past 25 years. User autonomy has become a more important policy objective than equity of access or equality of opportunity, with a greater reliance on market mechanisms for delivering services. The public and politicians seem to be prepared to accept that competition, choice and decentralization may result in a widening of regional and geographical inequalities, and the erosion of the universal character of the welfare state. These developments reflect broader normative shifts in both societies, and are likely to continue and become more widespread in the future, as they will be strongly influenced by demographic and social factors, fiscal constraints and the policies of supranational bodies such as the European Union.     

Optimal policies for sin goods and health care: Tax or subsidy?

In this paper, we examine the optimal policies for sin goods and health care in a two-period economy. Individuals are myopic in the sense that they undervalue the utilities of future consumption and health quality. When investing in health care in the second period, individuals who have previously made myopic decisions may persist in their shortsighted consumption plans (persistent error) or recognize their mistakes (dual self). We show that, for persistent-error myopes, the first-best policy mix requires a subsidy on savings and a tax on sin goods. The health care should be taxed (subsidized) if the degree of myopia concerning future consumption is larger (smaller) than that concerning health quality. For dual-self myopes, the optimal policy for sin goods can be either a tax or a subsidy, depending on the relative degrees of myopia and the property of the health quality function.     

Information access: will make or break consumer-driven health plans

Consumer-driven health plans offer employers potentially significant cost savings. Yet such potential cannot be realized without greater consumer access to price, quality and treatment information. This article describes why consumer-based strategies have taken hold and how consumer-driven plan design and financial incentives are of only limited value in controlling costs. After reviewing the importance and availability of existing health care information, the authors suggest actions employers can take to ensure consumer-driven plans reach their potential.     

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.