bluuebunny/crossref_metadata_2025 huggingface dataset:
Health Care Policy Issues in the Drug Abuser Treatment Field
Authors: McAuliffe William E.
Published: January 2008

As we enter the 1990s drug abuse has once again become a major health concern, and for the first time the drug treatment field has had to address many of the policy, regulation, and planning issues resulting from cost inflation that have become commonplace in other parts of the health care field. To avoid serious errors and confusion, drug abuse health policies must recognize the very different needs of the public and private sectors. The public sector, where poor addicts receive drug treatment provided or purchased by the government, has long suffered from chronically inadequate funding. Although responses to several epidemics (heroin, crack, and AIDS) have produced periods of increased allocations for drug abuse treatment, more often than not long waiting lists at programs have rationed treatment to lower-income addicts seeking care. Low salary levels have limited the quality of public treatment services, and the absence of resources has hindered the development of programs that respond to new technical developments and drug abuse problems, such as the crack epidemic. Despite severe resource shortages, the public drug treatment system has sometimes used resources inefficiently, with little attention to appropriateness of admissions, lengths of stay, ambulatory treatment modalities, or varying levels of care. Public sector goals for the 1990s should include filling current shortages in drug treatment services, developing adequate long-term funding for treating addicts who lack third-party coverage, modernizing the treatment system, developing new patterns of practice that use existing resources more efficiently, and developing a plan for treating intravenous drug users infected with the AIDS virus. In the private sector, the advent of working- and middle-class demand for drug treatment in the 1970s and 1980s has produced a new drug treatment system that suffers from many of the policy problems common to the rest of health care. Drug abuse in the workplace has resulted in much wider coverage of substance abuse services by insurance companies and HMOs. The availability of third-party funds has spawned a for-profit chemical dependency treatment industry. The high cost of private residential treatment services has caused significant cost inflation. Cost-containment measures, which are a new phenomenon for this field and are inappropriate for the public sector, have led to the same confusion and debates that they have produced in other areas of health care. Policy and regulatory goals for the
Mental Health Policy for the 1990s: Tinkering in the Interstices
Authors: Bloche M. Gregg , Cournos Francine
Published: January 2008

That public policy has abysmally failed the chronically mentally ill seems beyond genuine dispute. Successive reforms have foundered on the familiar shoals of overblown expectations and insufficient resources. In this paper, we review current policies affecting the chronic and disabled mentally ill, and we consider some approaches to reform. We begin by trying to identify and characterize the chronically mentally ill and their disabilities. Next, we consider the chaotic patchwork of federal and state programs that has come to replace the asylum. We then criticize several competing models of reform that we believe fail to make an empathic connection with the mentally ill. Finally, we urge a strategy of limited reform consistent with available empirical data about program effectiveness and sensitive to the likely economic, political, and legal constraints of the 1990s.
Health Policy and the Politics of Research in the United States
Authors: Fox Daniel M.
Published: January 2008

During the past decade research has been more important to the health policy-making process in the United States than at any time in the past. This article describes and assesses three competing normative models for research on health affairs: economizing, social conflict, and collective welfare. The three models provide a context for the history of research bearing on health policy in the past half century, with particular pertinence to the years since 1980. The article concludes with a discussion of some of the consequences of the new legitimacy of research.
The Cost and Value of Second Surgical Opinion Programs: A Critical Review of the Literature
Authors: Lindsey Phoebe A. , Newhouse Joseph P.
Published: January 2008

Second surgical opinion programs (SSOPs) have been used since 1972 by both public and private insurers to improve the patient's information and decision processes and to reduce operative risks and costs attributable to questionable and perhaps unnecessary operations. This article reviews the literature on SSOPs. It considers whether SSOPs are effective mechanisms for reducing health care costs, how SSOPs affect outcomes, how physician errors affect the value of SSOPs, and what noncon-firmation rates and rates of surgery indicate about the appropriateness of operations. Although the literature varies in quality, all the studies fall short in one or more of the following dimensions: an appropriate control group, a comprehensive definition of cost and outcomes, and sufficient duration and scale to measure changes and use of medical services in a general population. Thus, the value of SSOPs remains an open question.
Expanding Health Insurance Coverage: Who Will Pay?
Authors: Cantor Joel C.
Published: January 2008

Recent discussions on extending health insurance to the more than thirty million uninsured Americans have focused on two strategies: expanding the Medicaid program and mandating that employers sponsor coverage for their employees. This analysis, using a microsimulation model of the U.S. health care financing system, suggests that these two options would result in very different distributions of financial burden. Employer-sponsored coverage is financed in a highly regressive fashion, in contrast to the Medicaid program, which is proportional to income. Furthermore, the burden of paying for health care under Medicaid varies little among generations, whereas the cost of employer-sponsored care is lowest in households headed by persons over sixty-five years old. Low health status populations do not pay disproportionately higher taxes or premiums to finance either the Medicaid program or employer-sponsored coverage. Their incomes, however, are more effectively protected by Medicaid, because it offers more comprehensive benefits.
Why Requiring Employers to Provide Health Insurance Is a Bad Idea
Authors: Swartz Katherine
Published: January 2008

There is mounting pressure at the federal (and state) level to require employers to provide health insurance to their employees. However, two quite different groups of workers could be affected by such a mandate. In addition, there are at least five major problems with requiring employers to provide health insurance. Chief among these is the further fracturing of the insurance market, so that the spreading of risk will be reduced, and only the young and healthy will be offered insurance at relatively low premiums. We should be designing a health insurance system that has both universal coverage and a cost-containment structure. Toward this end, we need to tackle issues that transcend alternative methods of financing health care in the U.S.
Maternity Care Financing: Universal Access or Universal Care?
Authors: Barber-Madden Rosemary , Kotch Jonathan B.
Published: January 2008

In an era of fiscal constraint, growing poverty, increased uninsuredness, medical liability problems, and increasing costs of maternity care, public and private financing mechanisms are changing rapidly and the service delivery system is increasingly fragmented. Despite the almost mercurial changes in the system, data from national studies show that access to care is a major problem affecting all childbearing women. This paper describes the three groups of women who require comprehensive maternity care, their insurance coverage, and the gaps for each group. It describes proposals which are currently under development to reduce uninsuredness and produce universal access and, in addition, presents an alternative plan for universal maternity care.
All-Payer Rate-Setting and the Provision of Hospital Care to the Uninsured: The New Jersey Experience
Authors: Rosko Michael D.
Published: January 2008

The New Jersey all-payer prospective payment system compensates hospitals for charity care and bad debts. This study examines its impact on the provision of care to self-pay patients. Self-pay patients include two types of uninsured individuals: (1) patients who cannot afford to pay their bill and (2) more affluent patients who can afford to pay but who evade collection. Using data for the period 1979–85, the study employed a sample of seventy-nine New Jersey hospitals that entered the all-payer system during the years 1980–82. A regression equation, which included independent variables to control for the community's pool of uninsured residents and the hospital's share of this pool, was estimated for the number of self-pay discharges. The results indicate that the volume of care provided to self-pay patients increased when the New Jersey all-payer system was introduced. The results also show that teaching hospitals and facilities in urban areas discharge a disproportionately large number of self-pay patients. Analysis of the operating margin ratio suggests that the all-payer system helped to restore the financial viability of hospitals that tend to provide larger amounts of services to the uninsured.
Overlooked Connections: Policy Development and Implementation in State-Local Relations
Authors: Paul-Shaheen P. A.
Published: January 2008

Increased public demand for health services, combined with fiscal and operating restraints, has led to the need for programs that will operate efficiently and effectively to achieve their objectives. Establishing such programs requires an understanding of the factors that contribute to their development and implementation. This in turn requires a greater understanding of the policy formulation and policy implementation processes. This paper uses a case study of Michigan's State/Local Cost Sharing Program to explore how policy formulation links to and influences implementation; it considers the interaction between the administrative and political processes and how they are affected by shifting power relations, constituencies, and the environment, and how in turn these affect program leadership and operating policies. The paper develops a model as a framework for monitoring the course of the program through the policy cycle and recommends that the policy process be considered as dynamic, interactive, and evolutionary. The case study approach allows for a greater understanding of the phases of the process, their interaction, and their impact on specific policy outcomes.
The Politics of Universal Access: The Massachusetts Health Security Act of 1988
Authors: Goldberger Susan A.
Published: January 2008

This article analyzes the passage of an unprecedented state law, promising every resident access to affordable health insurance. The Massachusetts Health Security Act of 1988 was the product of a set of political and financial pressures that had been developing for nearly a decade. Hospital, insurance, and business interests were unable to reach a new accommodation on hospital payment. This logjam created the opportunity for a policy breakthrough, but did not inherently lend itself to progressive reform. It was consumer activism that forced the traditional powers in health policy to address the interests of the uninsured. By imposing a more public-interest agenda on the process, consumers were able to change the configuration of the stalemate, but could not resolve it. The particular terms of the stalemate, however, made possible a new, more aggressive role for state government in health policy. Unable to satisfy their competing interests within a policy framework that had universal access as a goal, traditionally powerful interest groups found themselves increasingly dependent on the state to broker a new agreement. While the many concessions made to these groups are likely to prove to be the bill's undoing, the unraveling of the agreement will not end the story. The same pressures which led to passage of the Massachusetts law and which are now causing other states to act will continue to exert their effect until a more durable solution is found.
The Slippery Slope of Health Care Finance: Business Interests and Hospital Reimbursement in Massachusetts
Authors: Kronick Richard
Published: January 2008

In 1988 Massachusetts enacted a bill, popularly known as Health Care for All, which promised that by 1992 every Massachusetts resident would have available affordable insurance for basic medical expenses. This legislation was one of a series of laws enacted over a period of six years which progressively improved access to care for the uninsured. The policy process which led to the enactment of these laws was strongly influenced by the interests of large employers. This article describes the series of access-expanding hospital reimbursement changes in Massachusetts in the 1980s and traces the connection between the involvement of business interests in the policy process and the outcomes that occurred; that is, it follows the slide of employers down the slippery slope of health care finance. The article also describes a potential implementation strategy for the Health Care for All legislation.
Technological, Economic, and Political Feasibility in Osha's Air Contaminants Standard
Authors: Robinson James C. , Paxman Dalton G.
Published: January 2008

In 1989, after almost two decades of substance-by-substance standard setting, the Occupational Safety and Health Administration (OSHA) promulgated its Air Contaminants Standard, imposing new exposure limits for 376 toxic substances encountered in U.S. industry. In marked contrast to earlier regulations, the Air Contaminants Standard has generated relatively little industry opposition. This paper analyzes the standard in the context of the twenty-year debate over the appropriate role for technological feasibility and economic compliance costs in occupational health policy. The political feasibility of the new standard is traced to OSHA's abandonment of “technology forcing” in favor of reliance on “off-the-shelf” technologies already in use in major firms. While important as an embodiment of OSHA's new “generic” approach to regulation, the Air Contaminants Standard cannot serve as a model for future occupational health policy, due to its reliance on informal, closed-door mechanisms for establishing regulatory priorities and permissible exposure limits.
Adult Day Care Regulation: “Déjà Vu All Over Again”?
Authors: Weissert William G. , Elston Jennifer M. , Musliner Melissa Constable , Mutran Elizabeth
Published: January 2008

We investigate what aspects of adult day care are regulated by licensure and certification requirements, whether differences exist among centers according to their regulatory status, and the relationship between regulatory status and satisfaction. The data come from a national survey of adult day care centers. We find that adult day care regulations are primarily structural in nature and that differences do exist among centers by regulatory status. Participants are very satisfied with the centers and their staff overall, especially at centers that are regulated; their satisfaction with milieu is less at regulated centers and with amenities is unaffected. Day care regulations have not been extended to the processes and outcomes of care as nursing home regulations recently have been. The choice that now faces policymakers is between increasing these regulations or relying on market mechanisms to protect day care participants.
Partnership as a New Strategy in Mental Health Policy: The Case of Québec
Authors: Boudreau Françoise
Published: January 2008

The notion of partnership is increasingly adopted as a sine qua non for the successful resolution of strategic problems in the field of human services. In this paper, I examine Québec's recent mental health policy and its operational definition of the concept. I then suggest some of the roots and reasons behind this province's adoption of le partenariat as the basis for policy. I suggest that it is a response to four key strategic problems: (1) the exhaustion of resources and allocation of losses; (2) the loss of faith in government and the consequent need to redefine the role of the state; (3) the loss of faith in professional knowledge and the increasingly forceful voice of alternative and “psychiatric survivor” groups; (4) the problem of overload in pluralist and competitive democracy and, related to this, the ubiquitous search for consensus and frictionless solutions. I conclude that in adopting the language of partnership, policymakers in Québec and elsewhere are being seduced by the possibilities of neocorporatist ideas applied to the management of human services.
Has PPS Increased Medicare Expenditures on Physicians?
Authors: Holahan John , Dor Avi , Zuckerman Stephen
Published: January 2008

We use data from 1983 and 1985 on the volume of Medicare physician services to analyze whether Medicare's Prospective Payment System (PPS), which resulted in a significant decline in hospital spending, led to a partially offsetting increase in real expenditures for physician services. We also analyze the effect of increases in assignment rates, increasing incomes of the elderly, and other factors on real expenditures during this period. Our main conclusion is that PPS has at most a small positive effect on real physician expenditures. Because people spent less time in the hospital, Medicare physician spending declined; but because of incentives to shift radiology and other services out of the hospital, some of this decline was offset. We also conclude that the sharp increase in Medicare assignment rates over this period, along with the rising incomes of the elderly during this period, contributed to the observed growth.
Will Paid Home Care Erode Informal Support?
Authors: Hanley Raymond J. , Wiener Joshua M. , Harris Katherine M.
Published: January 2008

One of the main barriers to the expansion of paid home care for the chronically disabled is the fear that policymakers have that it will cause friends and relatives to curtail their informal caregiving efforts. Using the first wave of the National Long-Term Care Survey, we examine whether the amount of paid home care used by disabled elderly persons had a significant influence on the amount of informal support they were receiving. Results from a two-stage least squares regression analysis suggest that the amount of informal home care received was not significantly affected by the level of formal care. This conclusion held for subgroups of formal care users most likely to exhibit substitution: those without cognitive problems, the disabled elderly with above average income, and persons who lived alone. Even the more severely disabled elderly, who are the target of most proposals to expand paid home care, did not substitute paid care for unpaid. Thus, our study suggests that an increase in paid home care will not erode informal support.
Administrative and Policy Issues in Reimbursement for Nursing Home Capital Investment
Authors: Boerstler Heidi , Carlough Tom , Schlenker Robert E.
Published: January 2008

The way in which states reimburse for nursing home capital costs can create incentives for nursing home owners to use the home primarily as a vehicle for real estate speculation, with potentially adverse consequences for patient care. In order to help promote and control the stability, adequacy, and quality of capital investment in long-term care, an increasing number of states are using a fair-rental approach for calculating capital reimbursement. In this article we compare the fair-rental approach with traditional cost-based capital reimbursement in terms of administration and policy. We discuss issues of concern to the state (cost and reimbursement design options) and the investor (after-tax cash flows, rate of return, etc.). Our analysis suggests that fair-rental systems may be superior to traditional cost-based reimbursement in promoting and controlling industry stability, while at the same time providing an adequate return to investors, without incurring long-term increases in the costs of administering programs.
Further Issues in Small Area Variations Analysis
Authors: Stano Miron
Published: January 2008

In this article, I examine Wennberg's “practice style” hypothesis and the literature on variations among small areas. According to Wennberg, geographic variations in rates of per capita use for many clinical procedures arise mainly from differences over what constitutes appropriate care. I show, however, that the role of practice style in explaining variations among areas has not been clearly demonstrated. I also argue that the practice style hypothesis can neither be established nor refuted by the methods traditionally used to study small areas and, moreover, that inferences about practice style variations cannot be drawn from differences among areas in their rates of use. I thus conclude that more research at the micro level in the practice patterns of the individual physician is needed before major health care initiatives based on small area methodology are undertaken.
The Public Presentation of Blue Cross, 1935–1965
Authors: Rothman David J.
Published: January 2008

I explore the public presentation of Blue Cross, examining in detail the political, cultural, and institutional messages that shaped its advertising. Blue Cross advertisements had the twin purpose of attempting to increase the number of its own subscribers while criticizing the idea of a national health insurance policy. These twin aims did structure the Blue Cross campaigns but may well have worked at cross-purposes.
Sharing Governmental Authority: Blue Cross and Hospital Planning in New York City
Authors: Fox Daniel M.
Published: January 2008

Hospital planning in New York has been since the 1930s an intensely political process with high stakes. The leaders of Blue Cross and their allies used the hospital planning process in the city and the state as a means to extend and protect corporate authority in what they took to be the public interest. When Blue Cross was established in the 1930s, its leaders used the mechanisms of formal planning as part of their solution to pressing problems in the organization and distribution of hospital services. In the decade after World War II, Blue Cross had an immense impact on hospital planning in New York as a result of its growth and its underwriting policies. Conflicts between Blue Cross and state regulators beginning in the 1950s led to a new formulation of the politics of planning. Blue Cross became a partner with the state in regulating hospitals. The state and Blue Cross behaved as co-regulators until the 1980s. The interpretation in this paper revises the earlier accounts of health politics in New York by Law (1976) and Alford (1975).
Empire and the Business of Health Insurance
Authors: Sapolsky Harvey M.
Published: January 2008

I examine the development of privately provided insurance since World War II, giving special attention to Empire Blue Cross, and argue that the competition between employers and unions for the loyalty of workers after the passage of the Taft-Hartley Act helped diffuse private health insurance benefits already favored by federal policies. For-profit insurers did not challenge the privileged status of Blue Cross plans because they recognized the political benefits that the plans offered and because they did not wish to offend the plans' sponsors. A relatively easy and profitable business, health insurance has been greatly disturbed by the system inflation accompanying the introduction of Medicare and Medicaid programs. Now self-insurance and various managed-care schemes are major threats. The future may bring consolidation and the strengthening of pools, just the opposite of today's system fragmentation.
New York's Blue Cross and Blue Shield, 1934–1990: The Complicated Politics of Nonprofit Regulation
Authors: Marmor Theodore R.
Published: January 2008

The story of New York Blue Cross is one of complex interaction with state and federal regulators and also with hospitals, the medical profession, commercial insurers, and the public, who make up the regulatory environment. Negotiation, cooperation, and adaptation among parties whose goals and assumptions were partly parallel characterize the relationships. As we can see from New York Blue Cross's origins and its role in the development and administration of certificate-of-need legislation, Medicare, insurance practice and regulation, and hospital rate setting, this story does not represent the capture of government by a special interest, nor the gradual souring of a public interest organization, nor disinterested and distant government regulation.
Will Medicare Beneficiaries Switch Physicians? A Test of Economic Competition
Authors: Rice Thomas , Nelson Lyle , Colby David C.
Published: January 2008

We assess the potential of increased economic competition by examining whether Medicare beneficiaries are willing to switch to physicians who agree to accept all services on assignment. Data come from a survey of Medicare beneficiaries conducted in November 1988. Our principal finding is that beneficiaries are not sensitive to price when making decisions about whether or not to switch physicians. Less than one-half of 1 percent of the sample had switched physicians for economic reasons in the year prior to the survey. Furthermore, willingness to switch was not correlated with ability to pay. We conclude that policies aimed at altering consumer demand may not be the most effective way to control Medicare costs.
The Media and the Fate of the Medicare Catastrophic Extension Act
Authors: Fan David P. , Norem Lois
Published: January 2008

We examine the Medicare Catastrophic Extension Act of 1988, which was repealed in 1989, finding a broad range of messages on this controversial legislation in the press. The time needed to craft compromise legislation in response to objections to the original bill was cut short by the impending deadline for payments by the elderly, January 1990. Outright repeal rather than modification was the result. Our study confirms earlier studies, which show that trends of opinionin this case that of senior citizens over 65 years of agecould be forecast from mass media stories, and is consistent with the notion that legislation occurs in a climate shaped by the media. In addition to being a key conduit for passing information and pressures to the public and lawmakers, the media could also serve to indicate the impact of messages passed through other channels, such as direct mailings.
Hmos for Medicaid: The Road to Financial Independence Is Often Poorly Paved
Authors: Buchanan Joan L. , Lindsey Phoebe A. , Leibowitz Arleen , Davies Allyson Ross
Published: January 2008

During the 1980s both the federal government and the private sector articulated policies to encourage the development and participation of health maintenance organizations (HMOs) in the Medicaid program. However, the policies, intended to save costs, limited the ability of new HMOs to achieve financial independence. New plans that emphasize Medicaid participation have few, if any, options on benefit design or in setting capitation rates. Relative to fee-for-service Medicaid programs, their costs to provide services may be quite high, as they have neither the buying power nor the ability to impose discounts. As a consequence, plans must focus their financial planning efforts on targeting and attaining a stable enrollment base and on controlling the amount of services provided, tasks that are difficult for all HMOs. Achieving a stable enrollment base is particularly hard because Medicaid eligibles have few incentives to enroll and once enrolled often lose their Medicaid eligibility. Traditional HMOs control the amount of services provided through physician selection, financial incentives on physicians, and monitoring and utilization review. Lack of information and the difficulty inherent in attracting sufficient provider participation limit the first two strategies, so new plans often adopt organization structures that rely heavily on monitoring activities. Unfortunately, management information systems for HMOs are often the weakest link. We discuss the tasks and present data on financial planning, on putting financial plans into operation, and on monitoring progress toward financial independence for a set of ten demonstration projects sponsored by the Robert Wood Johnson Foundation.
Decisions without Consequences: Cost Control and Access in State Medicaid Programs
Authors: Barrilleaux Charles J. , Miller Mark E.
Published: January 2008

States have implemented a number of strategies to provide services, pay providers, and control Medicaid spending. We test the effects of some differences in state Medicaid policies on program enrollees' access to and use of health care services. Logistic and OLS regression analyses of cross-sectional data indicate that these policies exert significant influences on enrollees' access to health services but have a weaker direct effect on their use of them. However, we find evidence that utilization is affected indirectly (through increased access) by state policy decisions. Somewhat surprisingly, Medicaid policies designed to contain costs by limiting utilization appear to affect neither access nor utilization. Medicaid enrollees have greater access to a private physician in states with higher physician reimbursement and additional Medicare insurance for their enrollees. Other nonpolicy variables with pronounced impacts on access to private office physicians include race and the availability of private insurance.
Medicaid and Access to Child Health Care in Chicago
Authors: Fossett James W. , Perloff Janet D. , Kletke Phillip R. , Peterson John A.
Published: January 2008

In this article we examine how increasing the reimbursement of physicians and expanding Medicaid eligibility affect access to care for children in Cook County, Illinois, which overlies Chicago. Using Medicaid claims and other data at the zip-code level, we compare the places where Medicaid children live with the places where all the physicians who treat children and those who accept Medicaid patients have their practices. Our findings suggest that the recent changes in legislation are unlikely to benefit extremely poor children, who are more likely to live in depressed inner-city areas, where there are few physicians. “Near-poor” children whose homes are dispersed throughout the county, who are now eligible for Medicaid as a result of the recent changes, are likely to see improvements in their access to care. Further changes in policy, aimed at enhancing the capacity of institutions providing care, could improve access for the children of the inner city.
A Blip on the Radar Screen: Formulation and Implementation of the Medical Waste Tracking Act
Authors: Nakamura Robert T. , Church Thomas W. , Cooper Phillip J.
Published: January 2008

We use the passage and implementation of the Medical Waste Tracking Act of 1988 (MWTA) to explore the implications of health and environmental policies that are formulated in the context of events defined politically as a crisis. Building on Kingdon's (1984) “garbage can” model of policy initiation, we assess the linkage between a policy environment that provides strong but short-lived support for the enactment of a policy and its subsequent implementation. Among the implications of the less-than-impressive substantive results of the MWTA is the lesson that while a crisis can tilt the political balance in favor of regulatory legislation, it cannot as readily produce the consensus required to sustain that regulation at the levels promised in the legislation.
Financing Universal Health Insurance: Taxes, Premiums, and the Lessons of Social Insurance
Authors: Bodenheimer Thomas , Grumbach Kevin
Published: January 2008

In a society with strong antitax sentiment and large government deficits, the enactment of universal health insurance is blocked by an impasse over financing. The two chief mechanisms for funding universal health insurance are taxes and insurance premiums. Taxes and premiums are not distinct entities; rather, a spectrum of financing methods exists with varying tax-like and premium-like features. Premium-like financing tends to be voluntary and earmarked for health care, with coverage contingent upon making payments and payments going to private insurance firms. Tax-like financing, in contrast, tends to be mandatory and not earmarked for health care, with coverage not dependent upon making payments and payments going to governments. Over the past century, most industrialized nations have developed highly popular social insurance programs to cover periods of retirement, disability, unemployment, and payment for medical care. Social insurance constitutes a blend of tax-like and premium-like features, offering lessons that might assist in breaking the current impasse over universal health insurance financing.
Prospective Payment for Psychiatric Services
Authors: Dada Maqbool , White William D. , Stokes Houston H. , Kurzeja Paul
Published: January 2008

The Medicare prospective payment system (PPS) was designed to create financial incentives for providers to contain costs, but it also places them at financial risk. The system includes provisions to mitigate the risk, but, because they may have limited effectiveness in the case of psychiatric services, specialty psychiatric hospitals and eligible psychiatric units of general hospitals are exempt from the system. A variety of payment options have been proposed to integrate these facilities into the PPS. Empirical studies on the financial risk entailed by these options have focused on their impact on risk in the long run. Our study uses a broader framework to evaluate their impact on short-run as well as long-run risk. We use Medicare discharge data for 1985 to simulate alternative PPS payment options under the assumption that treatment patterns remain fixed. Our results suggest that under current PPS payment rules, risk would be high for psychiatric specialty hospitals. However, alternative options exist, which could substantially reduce their exposure to risk, while maintaining incentives to contain costs.
Competition and Community Mental Health Agencies
Authors: Clark Robin E. , Dorwart Robert A.
Published: January 2008

Community mental health agencies (CMHAs) provide most of the institutional outpatient treatment in the United States. A great deal of this care is given to clients at prices below the actual cost of the service. As the number of mental health providers increases, the question of how competition shapes the performance of CMHAs becomes more important. We use a two-stage least-squares model to examine how competition from other outpatient facilities, psychiatrists, and health maintenance organizations (HMOs), coupled with demographic, economic, and organizational factors affects subsidized care in CMHAs. Our analysis shows that competition from psychiatrists and HMOs reduces the number of subsidized visits that CMHAs provide and that agencies in urban areas and those initiated with federal funds provide more subsidized care. By restricting access to outpatient treatment, competition may have adverse long-term consequences for potential clients and for state mental health authorities.
The United States: Breakthroughs and Waste
Authors: Reinhardt Uwe E.
Published: January 2008

The health system of the United States is in a paradoxical position. At its best, the system is a magnet for those seeking the latest technical breakthroughs. It can offer that excellence because there have never been effective financial constraints on the imagination; the system has become a major economic frontier, at which professional and other entrepreneurs successfully seek their fortune. At the same time, the system is leaving increasing numbers of Americans frustrated and disillusioned. It is beset by excess capacity in many areas, is needlessly expensive, and often bestows unnecessary health services. Yet only the experts are aware of these flaws; most Americans still express high satisfaction with the quality of the services they receive from their doctors and hospitals. The public's major misgivings arise over the awkward and inequitable way in which American health care is financed. The typical private health insurance policy, for example, is tied to a particular job. If the job is lost, so is the health insurance. Furthermore, these policies are priced on actuarially “fair” principles, so sick individuals are forced to pay higher insurance premiums than relatively healthy ones and chronically ill persons often cannot obtain health insurance coverage
The United Kingdom: Effective, Efficient, Equitable?
Authors: Culyer A. J. , Meads Andrew
Published: January 2008

The British National Health Service (NHS) has, since its inception, aimed to make health care available to all regardless of income, and it has managed to achieve this goal while keeping costs lower as a proportion of the gross domestic product than many Western countries and at the same time assuring equitable distribution of resources regionally. Until the reforms introduced by the 1989 White Paper, the NHS was characterized by centralized financing and regulation; despite some problems in the delivery and management of care, the system was a popular one. The new reforms hope to enhance efficiency in the NHS by stimulating competition and further decentralizing the management of health care. However, it is not at all certain that in practice the reforms will have the desired effect. Initial costs will be high, people may not respond to incentives as predicted, and the quality of care and access to it could well deteriorate. Nations planning to use the U.K. system as a model are advised to use caution.
Germany: Solidarity at a Price
Authors: Schulenburg J.-Matthias Graf v.d.
Published: January 2008

The health care system of the Federal Republic of Germany relies on the private sector for the financing, delivery, and payment of care. However, the private sector is regulated by the government to ensure that broad societal interests are being fulfilled. The system has managed to achieve comprehensive coverage and equal access for all citizens, freedom of choice for patients, high-quality medical care, and cost containment. The reason for this success is a combination of decentralized power and decision making and the establishment of an effective negotiation system that takes place at federal, state, and local levels. The system suffers from some problems, however, which will have to be addressed: the present structuring of hospital and ambulatory care results in excessively long lengths of stay in hospital; drugs are overprescribed; the supply of health professionals does not meet the country's needs; more nursing homes are needed; and eastern Germany must be fully integrated into the system.
Private Outlets for Public Limitations: The Rise of Commercial Health Insurance in Israel
Authors: Cohen Marc A. , Barnea Tamara
Published: January 2008

In recent years, dissatisfaction with aspects of the Israeli health care system has grown. Labor conflict and unrest, long waits for elective surgery, increases in out-of-pocket payments for health care, and declining government investment have given rise to a new phenomenon: the increasing use of private services. This has led consumers to seek financing sources for their private care and created opportunities for commercial insurers and sick funds to offer new insurance packages to meet this demand. As a result, over the last five years more than twenty commercial health policies and four mandatory supplemental policies provided by the sick funds are currently on the market. The market for these policies is small but growing, with consequences for the cost and quality of care, access, the level and composition of national expenditures, and the allocation of resources to both the public and private health systems. As the balance between private and public financing changes, so too do the trade-offs between differing objectives. Greater private pluralism and competition at the financing level have many advantages but also make it more difficult for government to manage the tradeoffs that occur. Thus, a changed emphasis in government regulation and policy-making is required.
Health Policy Regimes and the Single European Market
Authors: Altenstetter Christa
Published: January 2008

I examine the potential effects of the creation of a single European market on the health policy regimes of the twelve member states of the European Community (EC), arguing that few changes can be expected in the basic nature of those regimes and that a Community-wide health policy regime is unlikely to emerge in the near future. Domestic health policy regimes and care systems will remain the dominant approach to health care delivery, and it is not likely that the American approach will be adopted. However, EC legislation designed to create favorable trade, economic, and fiscal conditions may affect key industries like pharmaceuticals and health insurance, with consequences for national health policy regimes. Patterns in Community-wide policy-making suggest that it will become increasingly difficult to define health issues in purely domestic or international terms.
Pharmaceutical Regulation in the European Community: Barriers to Single Market Integration
Authors: Orzack Louis H. , Kaitin Kenneth I. , Lasagna Louis
Published: January 2008

The European Community (EC) plans to create a single market for pharmaceutical medicines, but the drug industry is closely linked to cultural and societal values concerning health; to the national regulatory agencies responsible for the evaluation of safety, quality, and efficacy of new drugs; to multinational and domestic companies competing in national and international markets; and to varied interest groups of professionals and consumers organized along national and multinational lines. We review the history of the EC's policy proposals, examine reactions from all these interested parties, and assess the prospects for integration into a single market. The contentious debate that continues among the parties over national prerogatives, industrial interests, professional mandates, and consumer concerns clouds the prospects for a system of centralized drug registration that will be acceptable to all EC member states.
Falling Through the Cracks: Care of the Chronically Mentally Ill in the United States, Germany, and the United Kingdom
Authors: Hollingsworth Ellen Jane
Published: January 2008

In comparing the development and strength of community-based services for the chronically mentally ill in the United States, Germany, and the United Kingdom, I analyze how the structure of each country's general medical system has influenced services for the chronically mentally ill and the extent to which more universal medical care systems are associated with stronger community-based systems for the mentally ill. Community-based services are frail and inadequate in all three countries, in each country for different reasons. The specifics of organization of the health care system seem less important in shaping these outcomes than the status of mental health care as a national priority.
Residential Care for the Elderly
Authors: Alber Jens
Published: January 2008

This article maps variations in a standardized way in residential care for elderly people in three Western nations. Measured by the number of available places per person aged sixty-five and over and by the number of staff members per bed in nursing homes, the United Kingdom has the most highly developed standards. The United States ranks second, with Germany lagging considerably behind. The variations are explained by four variables: the pressure of the problem, as defined by the percentage of the population aged sixty-five and over; the caretaker potential in the family system, which alleviates this pressure; the structure and financing of the supply of residential care; and decision-making procedures in health care policy-making. My analysis emphasizes the last two variables. In the United Kingdom and the United States, the public and private providers who supply care have either political or market incentives to expand their services. Germany's mix of public and private, by contrast, is dominated by voluntary associations that are neither responsible to an electorate nor allowed to make profits. Thus, their clients do not have opportunities to articulate their needs. Health care decision making in Germany takes place through a collective bargaining process between the sickness funds and the providers. In such a system, the interests of groups who are not represented at the negotiation tablesuch as the elderlytend to be neglected. A national health system of the British type links political decision makers via the election mechanism more closely to the concerns of the public. As older people represent growing proportions of the electorate, their needs find more adequate consideration in the policy process. In the United States, political officeholders also have to pay attention to the needs of increasingly organized older people, since the tax-financed and federally regulated Medicaid system is largely responsible for financing long-term care for the elderly.
Controlling Resurgent Tuberculosis: Public Health Agencies, Public Policy, and Law
Authors: Gittler Josephine
Published: January 2008

The reappearance of tuberculosis as a serious public health threat points up the fallacy of the widely held assumption that medical science had conquered the communicable diseases that were once leading causes of morbidity and mortality. In devising a strategy to prevent the spread of TB, public policymakers must adapt traditional TB control measures to reflect the current problem. Such a strategy can and should include the appropriate use of governmental coercion to compel observance of public health TB control measures. Public health approaches to control of human immunodeficiency virus, with their emphasis on the voluntary cooperation of those infected and at high risk for infection, are not a model for effective TB control. Additional resources, while needed, will not alone enable public health agencies to bring TB and other communicable diseases under control. In the present debate over health care reform, little attention has been paid to the importance of public health agencies in protecting the public health. The resurgence of TB is a warning of the consequences of neglecting public health agencies and ignoring the socioeconomic problems that underlie it and other communicable diseases.