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.     

Health care reform and reform for health: creating a health system for communities in the 21st century

If we are to improve the health of the population and reduce the inequalities in health that plague our communities and our planet, we will have to give greater attention to the determinants of health. The reform of the health care system, necessary though it is, will never be sufficient; we need to reform our whole society and in particular to focus on human rather than economic development. At the community level we need to create healthy communities that are “health-creating systems” of environmental, social and human development, as well as health care systems that focus first on improving and maintaining health. Such a “bottom-down” health care system would see the hospital become once again the place of last resort (but still a potentially important partner in creating healthier communities) and would focus instead on how to provide health promotion and health care from the household level up.     

Epilogue: health care reform and productivity

Only a health care system that balances the best interests of consumers with those of employers and government payers will ultimately provide quality care at manageable costs. These need not be opposing interests.     

Health insurers' operations in the face of health care reform: An analysis of the Supplemental Health Care Exhibit

The Patient Protection and Affordable Care Act (ACA) introduced significant changes to the health insurance marketplace in the United States. The act also imposed reporting requirements on insurers. The law has required insurers since 2010 to file yearly the Supplemental Health Care Exhibit (SHCE). The SHCE provides unique information on how health insurers operate. We analyze data in the SCHE to understand how insurers have complied with one of the major new regulations affecting health insurers' operations arising from the ACA—the Medical Loss Ratio (MLR) Provision. This requires that insurers spend a minimum percentage of their premium revenue on medical claims, quality improvement expenses, and deductible fraud and abuse detection and recovery expenses. Our analysis of the 2010–2017 SHCE indicates that insurers' underwriting performance worsened in the early years of the ACA as they worked to increase MLRs to become ACA‐compliant. Analysis of the SHCE further reveals that insurers' profits from managing uninsured plans grew as the profitability of underwriting insured plans decreased. Future research on health insurer operations is warranted. The currently underutilized and data‐rich SHCE provides unique information that makes future research possible.     

Employee communications and health care reform

The Patient Protection and Affordable Care Act (PPACA) has made health care reform a reality. Although many of PPACA's details are still unclear to many employers, and most of the act's major reforms will take effect over the next several years, companies have reason to begin preparing for change and enough information to begin a communications effort with employees. The authors describe a number of immediate actions that employers should take to make the most of their own understanding of PPACA as it develops, as well as help their employee benefits leaders make the most informed decisions about when and how to communicate with employees about the law and its impact on their group health plan coverage.     

Health care : Planning, policies, and incentives

In theory, health planning is a detailed and rational corporate attempt to handle broad social problems. But in practice it tends to be incremental—an institutionalised bargaining system which too often neglects the larger issues in favour of marginal adjustments. Mixed scanning, the detailed examination of selected, feasible proposals, combines the best features from theory and practice. Implementation still depends on the recognition of powerful interest groups (eg doctors, managers) and the inclusion of incentives to redirect their activities. Better planning does not guarantee better health—the influence of lifestyle and environment must not be neglected.     

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.     

No new state tax: universal health care coverage for children in Florida

Florida, which this year passed a sweeping health reform measure, is considering use of a Medicaid expansion option to revamp health care delivery for its children.     

Health care fraud control: understanding the challenge

The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control.     

Health care consumerism: engaging the real buyers--employees

Many employers have begun moving toward health care consumerism strategies designed to encourage employees to take more responsibility for their health care and the cost of that care. Recent surveys suggest ways employers can ensure their consumerism strategies succeed in engaging employees and, ultimately, encourage employees to change their behavior. This article describes what those surveys reveal about employer and employee perspectives on consumerism and suggests steps employers can take to align their interests with those of their employees in order to manage the demand for and use of health care.     

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.     

Consumer-driven health care: the future is now

Given that managed care seems to have run its course, employers are forced to deal with escalating health care costs by reducing benefits and lowering pay--or are they? Why not bring the power of the responsible, informed consumer to health care? Consumer-driven health care offers a new, economically rational direction that can simultaneously address the needs of both employers and employees. This article reviews the factors leading to the need for consumer-driven health care and describes the characteristics and benefits of its current and next generations of development.     

Health care fraud: a primer on the schemes and the tools to fight health care fraud

As the national debate over health care reform moves forward, one issue with which policy makers must grapple is the percentage of health care dollars lost to fraud and abuse. The General Accounting Office estimates that as much as ten percent of total health care dollars are lost to the inappropriate, and in some cases criminal, practices of health care providers. This article discusses the characteristics of the health care industry that make it particularly susceptible to abuse and then reviews the efforts by the Office of Inspector General, Department of Health and Human Services, to deter and punish those who defraud the federal health care programs.     

Health care regulation and the operating efficiency of hospitals: Evidence from Taiwan

Using data from the Annual Survey of Hospitals compiled by the Department of Health in Taiwan for years 1994 through 1997, we employed Data Envelopment Analysis (DEA) to evaluate the impact of a National Health Insurance (NHI) Program on the operating efficiency of district hospitals in Taiwan. We find that, on average, efficiency of district hospitals in Taiwan decreased following the implementation of the NHI Program. Our results are robust to the inclusion of control variables that have been shown to affect hospital operating performance in prior research, and alternative efficiency measurements.