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From Health Affairs
The Future of Health Insurance Web Forum
Is There Hope For The Uninsured?
Uwe E. Reinhardt
In an anecdote popular on the conference circuit, an American health policy analyst who has ascended to heaven asks God, "Will there ever be universal health insurance coverage in the United States?" "Perhaps," sighs God, "but not in my lifetime." This paper argues that this tale accurately describes the prospect of covering the uninsured in this country. Neither moral sentiments among a majority of U.S. political leaders, economic self-interest among those who would have to pay for universal health insurance, nor political pressure from the uninsured and likely-to-beuninsured will provide a sufficiently strong imperative to move this country toward universal coverage soon, if ever.
The Politics Of Health Reform: Why Do Bad Things Happen To Good Plans?
This paper examines political feasibility and its implications for health reform. I discuss the political obstacles to health reform in the United States, disentangling perennial barriers from contemporary constraints. I then explore major reform options and their political prospects. I argue that while incremental reform now appears to be the most feasible option, the political climate may change in a way that permits a bolder vision. Moreover, incremental reform may not be sustainable in the long run, for the same reason that makes it politically popular now: It does not change the status quo in the health system.
Americans' Views Of The Uninsured: An Era For Hybrid Proposals
Robert J. Blendon, John M. Benson, and Catherine M. DesRoches
Data drawn from ten recent public opinion polls show that the issue of the uninsured is likely to become more visible on the U.S. agenda, although not as prominent as it was in the early 1990s. Although there is no public consensus on any single approach, a hybrid plan-which leaves workplace insurance in place and includes elements of several proposals now being discussed to cover more of the uninsured-offers the possibility of public support. The critical issue is whether or not there will be public support in the future for raising revenues to pay for major expansions in coverage.
Building On The Job-Based Health Care System: What Would It Take?
Jack A. Meyer and Sharon Silow-Carroll
Recent surveys indicate widespread public support for reforming health care by building on our mixed public/private system. The authors present a blueprint for such reform, along with design choices and their implications, which would improve access, cost control, and quality. Requiring employers to provide coverage or at least to help workers obtain group insurance, combined with income-based premium subsidies, expanded public programs, and backup "insurance exchanges," would make affordable coverage available to nearly everyone. Cost control and quality improvement would be achieved mainly through pressures applied on the health care system by multiple, large purchasers that wield much buying power.
A New Medicaid Program
Lynn Etheredge and Judith Moore
This paper suggests a new federal-state partnership-a new Medicaid program-for coverage of the uninsured and longterm care. It discusses national eligibility standards, based on financial need (rather than categorical eligibility); buy-ins and reinsurance for high-risk populations; a national strategy of "Medicaid plus tax credits" to cover the uninsured; Medicaid long-term care with expanded eligibility, better financial protection, and home and community-based care benefits; quality initiatives; administration; and possible financing sources (such as estate taxes and an increased Social Security Disability Insurance wage base). Without a new mission and national standards, Medicaid will continue to grow in a patchwork fashion with huge gaps and inequities.
From the Milbank Quarterly Volume 81, Number 3
On Being a Good Listener: Setting Priorities for Applied Health Services Research
Jonathan Lomas, Naomi Fulop, Diane Gagnon, and Pauline Allen
Although there are numerous methods for setting priorities across health services, no equivalent attention has been given to ways of setting priorities for health services research. One of the greatest lessons from setting these priorities is that the involvement of users, while difficult to achieve, is central to clarifying the underlying values and assumptions often buried in technical, data-driven exercises. It also leads the users to greater ownership in and commitment to the eventual priorities. This article applies these lessons to setting priorities for applied health services research, outlined in a six-stage "listening model." The model is then applied to both an English and a Canadian case study, and the lessons from these experiences are summarized.
Redesigning Work Processes in Health Care: Lessons from the National Health Service
Chris Ham, Ruth Kipping, and Hugh McLeod
Healthcare reformers focus on changing work processes in order to improve performance. In the British national health service, a range of initiatives have been pursued, including total quality management, business process reengineering, and quality collaboratives. This article analyzes the impact of the national booked admissions program and its implications for the national health service and the current quality improvement programs. Although redesigning work processes can improve performance, the impact depends on local contexts for change and how the mechanisms of change are used. It is important to convince physicians that change will offer benefits to both them and their patients, and to modify cultures that resist new ways of working. It also is necessary to recognize the challenges involved in sustaining quality improvements, allow adequate time to change work processes, and establish long-term responsibility for quality programs.
The Labour Market Consequences of Race Differences in Health
John Bound, Timothy Waidmann, Michael Schoenbaum, and Jeffrey B. Bingenheimer
This article examines whether race and ethnicity disparities in health account for similar disparities in employment status and other laborrelated outcomes. Using white Americans as a reference, two population groups whose health is systematically worse than that of whites (blacks and Native Americans) are identified. Then the distribution of labour-related outcomes-employment status, earnings, participation in public transfer programs, and household income-is documented for these groups. Finally, how much these differences in health status account for differences in the groups' labourrelated outcomes is examined. Health disparities seem to contribute to the substantial difference in employment and participation in public transfer programs between whites and blacks and between whites and Native Americans. But health disparities account for a smaller portion of the substantial differences in household income and labour earnings across racial/ethnic groups.
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