As health care reform legislation enters a critical phase in Congress, it's important to keep our eye on the ball — elements essential to the success of any reform effort. In order to define those elements, we must have a clear understanding of the nature of the pathology in our dysfunctional health care system.
Modern high-tech health care is a right of the residents of most wealthy countries in the world - except the United States. America is exceptional in this regard. It is also exceptional in being the only wealthy nation where health care is considered to be a business.
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In many ways, the new book by David Blumenthal and James Morone is a fine dissertation on the role of the presidency and a succession of American presidents, stretching back to FDR, in the formulation of health care policy in the United States. But it does not address a central question. What are the barriers to reform of the American health-care system? Why has it been so difficult for American politicians to create a statutory right to health care for Americans - a right that every other affluent democracy created years ago?
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Often left behind instead of going to the dance, long term care may finally see its opening in health care reform. Until now, few reform proposals bothered with long term care (LTC) in spite of the fact that a much greater share of the population is at risk compared with the scope of the “uninsured” for general health care. In addition, social insurance advocates and private insurance supporters often were in an uneasy alliance around how to approach any LTC reform, further hindering chances to address it. But with the reform of health care likely this year, LTC supporters have, for the most part, coalesced around Senator Kennedy’s CLASS Act as the most likely ticket to the dance.Read More…
In 2006 the Netherlands implemented a new health insurance system that requires all citizens to buy health insurance from a regulated insurance company of their choice; insurers must accept all applicants; the government subsidizes children and low-income families. Recent Changes in Dutch Health Insurance analyzes the new Dutch system and considers whether it might serve as a model for the U.S. The working paper emphasizes some of the major differences between the Netherlands and the U.S., including the extensive role of the Dutch government in regulating the health sector and the egalitarian tradition in Dutch social policies.
Many proposals for expanding health coverage involve the creation of organizations to produce information on comparative effectiveness, make coverage decisions, manage the marketplace for health insurance, or offer a public health insurance plan. Designing Administrative Organizations for Health Reform describes proposals to create new entities or agencies as part of a reformed health coverage system, catalogs the major types of federal executive agencies and non-governmental entities, and considers some of the issues involved in choosing an appropriate organizational design. It concludes that organizations that use governmental powers and funds and make public policy need to be accountable as well as effective.
Health reform must recognize the extensive role of states in U.S. health policy and reconcile national consistency with sub-national diversity. Re-Figuring Federalism: Nation and State in Health Reform's Next Round draws lessons both from federal-state relations in Medicaid and from the experiences of three other federal countries—Canada, Germany and Switzerland. It concludes that universal health coverage is compatible with a federal system, but that the federal government needs to establish central rules of the game.
Designing a Mixed Public and Private System for the Health Insurance Market considers design features of a health care reform proposal that would offer a government-run health insurance plan alongside competing private plans in a government-run insurance exchange. The Medicare program provides a practical guide to the problems and opportunities offered by such a mixed public and private system. Since both public and private plans have inherent advantages and disadvantages, both plans can be offered on a relatively level playing field. Among the items to be considered in creating a level playing field are the benefit package, advertising and consumer information, risk selection and risk adjustment, the choice environment, default enrollment, provider payment rates, and the administrative structure.
Choices about covering the uninsured have implications for the feasibility of different approaches for controlling health care costs, and vice versa. In practice, some combinations may work together better than others and the interplay of different approaches to coverage expansion and cost containment is the focus of Cost Containment and Coverage Expansion. It begins with a brief review of whether coverage expansion and cost controls must go hand-in-hand. It then lays out the menus of commonly proposed coverage approaches and available cost control measures and considers how the two might go together.
The Regulation of Private Health Insurance examines the current role of health insurance regulation and the role that it could play in a reformed health care system. It begins by exploring the nature of health insurance and alternative approaches to regulation. It next considers the current status of state and federal health insurance regulation, both describing the development of health insurance regulation and examining arguments in support of and in opposition to regulatory interventions. Finally, it considers the kind of insurance regulation that will be needed in a reformed health care system, as well as the question of whether authority for insurance regulation should be placed at the federal or state level. It concludes that the best approach would be to develop national standards for health insurance enforced primarily at the state level.
The high administrative costs of the U.S. health insurance system have been a focus of discussion for decades. Simplifying Administration of Health Insurance finds ways to define and classify administrative costs, both of insurers and of other participants in the system, and summarizes the fragmentary estimates of how large these costs are. It discusses current efforts to reduce administrative costs, many of which have focused on standardizing and simplifying transactions among insurers, providers, and employers. Finally, it considers how various reform proposals, whether or not directly targeted at administrative costs, might reduce—or add to—the complexity of the current system.
Restructuring Health Insurance Markets examines six structural changes that could expand health insurance coverage, with special focus on the administrative issues: changes in rating rules, high risk pools, standard benefit plans, reinsurance, Section 125 plans, and insurance exchanges. It considers what benefits these changes might produce, how they can be most effectively structured, and how they can be implemented. From an administrative standpoint, it is critical that any set of policies be considered as a whole, with careful attention to their interactions, both to enhance their chances for success and to avoid unnecessary administrative burdens and duplication.
I have been very pleased to spend the last few days in Washington, DC and to participate in several meetings about retirement security. On Wednesday, June 17, I joined a group at the National Academy of Social Insurance at “The Quest for Adequate Retirement Income” a symposium focusing on current issues in the retirement system.
On Thursday [July 18th], I had the opportunity to meet with a number of plan sponsors who were discussing challenges in the retirement income system from their perspective. These large organizations were interested in providing retirement security to their employees, and frustrated at what often seems to be a stream of endless roadblocks.
Expanding health coverage will involve changes in the premiums and taxes people pay for health insurance and the amounts they pay out-of-pocket for specific health care services. Payment arrangements must generate sufficient revenue, promote efficiency in health care delivery, assure access to care for people who have low income or are in poor health, and minimize administrative costs and burden. Paying a Fair Share for Health Coverage and Care evaluates alternative approaches—including social insurance programs, means-tested premium assistance, and income-related cost sharing—according to these criteria.
The nature and significance of Social Security trust funds is sometimes misrepresented to the public. This appears to be the case in Social Security Brief #30 issued on May 12, 2009 by the National Academy of Social Insurance. The section of this brief entitled “Where does the Social Security surplus go?” states essentially the following:Read More…