Health Care Reform; What Should Be Done? What Will Work?

HEALTH CARE REFORM; WHAT SHOULD BE DONE? WHAT WILL WORK?

An Annotated Bibliography

Erin Paul[i]

Unlike most industrial nations, millions of Americans are going bankrupt due to their insurmountable health care costs. This Annotated Bibliography examines proposed reforms to the US system and explores reforms that have been implemented in other countries.

Health care reform has been in forefront of the US population’s consciousness over the past year. From a campaign issue to an issue of economic necessity, health care reform is being discussed by Politicians news reporters and average Americans. Everyone agrees that the system is broken, but no one can agree on what should be done to fix it. There have been many ideas thrown around from abandoning the employment based system completely and having individuals responsible for coverage, to moving to a single payer system where the government would provide coverage for all.

While some countries health care systems have been in place for decades, others have only recently addressed health care reform. Many countries including Thailand, Japan and Taiwan have moved to a Universal coverage system. As a result of these reforms, citizens are experiencing lowers costs and are overall satisfied with the quality of health care they are receiving. Costs are lowered by reducing duplication of services and government control of costs. While the health care systems in other countries have their problems, they all spend less of the GDP on health care then the US and their citizens spend less on average than US residents. These successes have not gone unnoticed by Americans and many of the proposals in the last election had their foundations in these delivery systems.

Here in the United States only Massachusetts has attempted to cover all of its residents with health insurance. Their approach has succeeded in covering most citizens and has attempted with mixed results to lower costs. Not to be left behind, the federal government has also attempted to address health care in recent years, passing an albeit confusing prescription health care plan as well and creating and expanding coverage for children through the SCHIP program.

What is needed in the US is a complete overhaul of the system. For profit companies are deciding what to charge, who to cover, and what type of care they will pay for. Quality health care should be the right of every American. In the wealthiest county in the world it is unacceptable that families are choosing between health insurance and food for their tables. Insurance companies should be not-for profit and should be regulated by the government. A system like that of Japan or Taiwan that requires everyone to participate is necessary to not only to cover everyone, but to lower costs. To ensure everyone, there will ultimately have to be government subsidies for those who are unable to pay for coverage. Furthermore, additional money will be needed to provide incentives for medical students to choose primary care as their specialty. The current system which pays surgeons and dermatologists exorbitant salaries makes it difficult for loan burdened students to choose lesser paying specialties. One way to give doctors incentives would be to provide bonuses for keeping patients healthy, an idea used in Britain. This would help ensure quality physicians in fields such as primary care, while saving money through prevention efforts on the part of physicians and patients.

Any healthcare plan must insure children; therefore an expansion of the Children Health Insurance Program would be needed. We know that children’s health predicts health later in life. Spending money to ensure healthy children will save money in the future. The concept of spending now to save later is hard to many to swallow, however with a system as broken as ours is, it must be a concept we embrace. Healthcare is bankrupting American; the time for reform is now.

REFERENCES

Health Care Struggles/Current Initiatives

Adler, Nancy & Newman , Katherine (2002). Socioeconomic Disparities in Health: Pathways and Policies Health Affairs, 21 N. 2, 60 – 76

Rosenbaum, Sara, Markus, Anne, Sonosky, Colleen. (2004). Public Health Insurance Design for Children: The Evolution from Medicaid to SCHIP, Journal of Health & Biomedical Law, 1-47. (website) (Last Visited: April 3, 2009).

Proposed Reforms

Barack Obama’s proposed health care reform initiative. [Available on-line; last visited Apr] www.whitehouse.gov

H.R. 676 Expanded and Improved Medicare for All Act; United State National Health Insurance Act. http://thomas.loc.gov/cgi-bin/bdquery/z?d109:h.r.00676 [Last visited; 3/30]

Thoughts on Proposed Reforms/Suggestion for Reform

Ani B. Satz, The limits of Health Care Reform, 9 Ala. L. Rev. 1451 (2008).

Gawand, Atul (2009), There to Here; How Should Obama Reform Health Care? Annuals of Public Policy, Vol. 84 pg. 26-32

Ten Health Care Financing Principles to Ensure Universality, Equity, and Accountability (Authored by student in Professor Randall’s class)

Massachusetts

Greenberg Traurig, April 2006. An Act Providing Access to Affordable, Quality Accountable Health Care; An Outline of the New Massachusetts Health Insurance Legislation and it Employers. Pg 1-4.

Devel L. Patrick, Timothy Murray, Judy Ann Bigby, (2009). Health Care in Massachusetts: Key Indicators 1-65.

Reform around the Globe

Gordon Liu, Zhongyun Zhao, Renhua Cai, Tetsuji Yamada, (2002) Equity in health care access to: Assessing the Urban

PBS Frontline, Sick Around the World April, 2008.
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries

Tewarit Somkotra, Leizel Lagrada (2008). Payments for health care and its effect on catastrophe and impoverishment: Experience from the transition to Universal Cover in Thailand Social Science & Medicine 67 ; 2027-2035.

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Health Care Struggles/Current Initiatives

Adler,Nancy & Newman , Katherine (2002). Socioeconomic Disparities in Health: Pathways and Policies Health Affairs, 21 N. 2, 60 - 76

This article focuses generally on socioeconomic disparities in health and does not specifically single out women in its discussion. From other research we know that the issues that face all low income people disproportionately impact women, therefore information regarding low socioeconomic populations in general do provide information about women.

In this paper Adler and Newman examine the many pathways in which socioeconomic status impacts health and implications for policy. The paper identifies four key causes of morbidity; Biological determinant, health care, environmental exposure, and behavior and lifestyle.

[1]

Of these four the researchers found that the last three are strongly impacted by socioeconomic status.

The article examines how US policy impacts health care, environmental exposure and behavior and lifestyle are impacted negatively by socioeconomic status and how policy often exacerbates the problem. While the article focuses on poverty and low income people in general, the examination of how policy, public health programs, and environmental exposures create a greater divide among people and ultimately their health.

The primary focus of article is a comparison of policies available to United States children under Medicaid and the State Children’s Health Insurance Program. The article examines both Medicaid and the State Children’s Health Insurance Programs and makes predictions about the future of both programs their potential impact on children’s health.

This article provides a good side by side comparison of Medicaid as compared to State Children’s Health Insurance Programs and their health care coverage of children. Additionally the article gives an insightful view into how states are implementing the State Children’s Health Insurance Program.

The article provides helpful clarification between both statutes and how each statute affects the other. Health care reform in the United States will include Children. Understanding the pros and cons of the current system for children will be critical.

Proposed Reforms

Barack Obama’s proposed health care reform initiative. [Available on-line; last visited Apr] www.whitehouse.gov

The website provides the goals that President Obama has for health care. The plan is not a complete over haul of the system, it instead attempts to increase the number of insured people will cutting down the cost of existing coverage. Ideas include requiring insurance companies to cover pre-existing conditions, require more businesses to provide coverage while attempting to offset those costs with tax breaks, and establish a national health insurance exchange that would allow small businesses to collectively buy into a larger group plan.

[2] The ideas for cutting costs include moving the country to an electronic system, focus on preventative health, and reduce prescription costs through importation.

The white house’s plan is just that a plan. While there are several ideas that many agree have merit, there are few details regarding implementation and cost. Electronic conversion for example, while a good idea has received criticism because the cost would be on doctors and hospitals who would in turn not see a return on the investment; that savings would go to the patients and insurance companies.

We will see how much of this plan will exist in the coming months as the budget is discussed and actual health reform bills make their way through congress.

H.R. 676 Expanded and Improved Medicare for All Act; United State National Health Insurance Act.

http://thomas.loc.gov/cgi-bin/bdquery/z?d109:h.r.00676 [Last visited; 3/30]

Introduced February 8,2005 – Sponsor’s Representative Kucinich and Representative Conyers

This bill would create a publicly financed, privately delivered healthcare system. The program would expand the existing Medicare program, to all residents living in U.S. territories. The program would be a single payer system and would transform the for-profit industry to a not-for profit one. There would be no co-pays under this system. Proposed funding for the program would include; maintaining current federal and state funding for existing healthcare programs, through employer payroll taxes, and other individual taxes.

[3]

Only institutions that are public and nonprofit institutions would be allowed to participate in insuring people. For profit institutions could sell insurance for coverage that did not duplicate benefits provided under the act, such as elective procedures. [4]

Funding for the program would come from reduction in the current health care costs based on a reduction in paperwork, duplication of services, etc. It would also come from the existing Government revenue sources, increases in personal income tax for the top 5%, and a small increase on payroll taxes. [5]

The last action taken on this plan was April 4, 2005 when the bill was sent health committee; it has not made it out committee. While this plan has not received traction in Congress, the proposal is one that would completely overhaul the system. This proposal is a good resource for those with more political clout to review and utilize.

Thoughts on Proposed Reforms/Suggestion for Reform

Ani B. Satz, The limits of Health Care Reform,

59 Ala. L. Rev. 1451 (2008).

This article takes on the challenges of healthcare reform directly pointing out the many challenges that face would be reformers. The author lays out the US system and its faults, pointing out that the US spends $1.9 trillion dollars on healthcare, 16.9% of our GDP, and 60% our total healthcare expenditures.

[6] Despite these facts, we are far from universal coverage. The author contends that our insurance system which attempts to cover everyone by providing minimal healthcare services.[7]

The article identifies two approaches for reform of the system. The first is addresses a paradox in the system and argues that there be greater access to some of the very technologies elevating the costs of health care under the current system, namely, high technology health care services.[8] The author states that predictive measures need to be available to all in order to improve outcomes and ultimately reduce prices.[9] Second, the author contends that the system must be altered to allow patients the ability to choose from a wide range of effective basic health care services.[10]

This article takes an interesting look at health care reform. It focuses on the need bring an archaic system in many ways into the 21^st century. While the goal is the same as many other reformers, provide quality health care for all, the reasoning and approach is unique. This article identifies many of the major deficiencies in the system and how they are crippling individuals with high health care costs.

The author provides many useful references to the reader, enabling them to delve deeper into the issue.

Gawand, Atul (2009), There to Here; How Should Obama Reform Health Care? Annuals of Public Policy, Vol. 84 pg. 26-32

The author examines how other countries came to reform their health care systems. He concludes that most occurred for various reasons, but few changes occurred because of ideology. The author points to World War II as a catalyst for change in England and France, resulting in two different systems.

Next the author looks at the theory of Path-dependence in relation to health care reform.

[11]

Arguing that choices made early in the process narrow the choices that are available later in the process. Applying this theory to the US health care system, the author argues that while a reform is needed, a complete reboot would create havoc and cause more harm.[12]

Gawand uses the confusion over the new Medicare prescription plan as an example of how a complete overhaul can have on health care delivery. He argues that while many are suffering the system is carrying for millions and even a short break in service could be detrimental. [13]

The author concludes that change in the health care system will have to be done by slowly altering the current system which cannot be completely overhauled. He favors incremental changes and points to Massachusetts reform as an example of working reform.

The author of this article is a physician who works in Massachusetts. He speaks from the perspective of a physician. This article provides the reader with what will likely be a new understanding of how and why Countries provide health care the way they do. It is helpful to understand that plans often evolved or were created out of necessity and not ideology. Furthermore the author raised many potential negative consequences to radical reform. While the article is may not be unbiased it is still a valuable food for thought.

Ten Health Care Financing Principles to Ensure Universality, Equity, and Accountability

(Authored by student in Professor Randall’s class)

The author provides a set of ten principles that are needed to ensure quality health care for all. The list’s places the goal of health above all others. It is a good reminder that in order for true reform to exist this end goal must not be far from the reformers mind.

The list continues by challenging reform to take away the money making middle man, to reduce the tiered system of care currently in existence in order to make the system one that will provide quality care to all. The author provides the ideal, the goals that must be in the fore front of legislature’s minds to obtain real reform of the system. The concrete details of bringing about this change are not included in this article. The author does provide useful foot noted references.

Massachusetts

Greenberg Traurig, April 2006. An Act Providing Access to Affordable, Quality Accountable Health Care; An Outline of the New Massachusetts Health Insurance Legislation and it Employers. Pg 1-4

This article was created by a firm with the goal of explaining the Massachusetts Health Reform Act An Act Providing Access to Affordable, Quality, Accountable Health Care (the Act). A brief history of the Act is provided, explaining that the goal of the 2006 legislation was to “make health insurance more affordable through a series of insurance reforms and subsidies.”

[14]

The article’s main focus is to outline the provisions of the act and how they could impact employers. Included as part of the Act is the Health Insurance Connector, which is designed to reduce the burden of health insurance to individuals and businesses by allowing them to use pre-tax dollars to purchase insurance directly, thereby reducing costs by 25%.[15]

The Act also lays out Insurance Market Reforms that include tying high deductable plans to health savings accounts, merging non- and small group markets, and lower cost plans for young people.[16]

Next the Act provides Subsidized Health Insurance, by providing coverage assistance for person that make up to 300% of the federal poverty level, but who do qualify for MassHealth (the Medicaid program). Individual under the Act are required to obtain insurance if it is available and will be covered by the State on a sliding scale.[17]

Under the Act employers with 11 or more employees have many new responsibilities for health care. These include a Fair Share Contribution which requires employers who do not provide health insurance to contribute about $295 a year for each employee.[18]

Employers who do not contribute will receive a “free rider” penalty.[19]

This article provides a quick and easy to read synopsis of the Massachusetts health reform Act. The reforms in Massachusetts are the only real attempt in this country to provide universal health care coverage and therefore are being examined closely by other lawmakers. This article does not have references and is meant only to provide readers with an overview of the Act.

Devel L. Patrick, Timothy Murray, Judy Ann Bigby, (2009). Health Care in Massachusetts: Key Indicators 1-65.

This is the latest quarterly report on the impact of Massachusetts health care reform. The report looks at cost trends in health insurance premiums, health plan financial performance, access to health care measures from the Division’s household survey, and other indicators of health care in Massachusetts.

Since the plans inception almost 500,000 people have obtained insurance. 187,000 of those people received this insurance through enrollment in private insurance.[20] As of September 30, 2008 81% of people received health insurance through a private group, 1% through individual purchase, 14% through Mass Health, and 3% through Commonwealth Care. [21] The report noted that while more Massachusetts employers were more likely to offer health care coverage, fewer employees were signing up for the coverage.[22] Employer’s contribution levels are lower than the national average. [23] The report showed a 32% reduction in the number of health safety net visits from 2007 to 2008.[24] (Visits by those not covered by insurance).

This report provides the reader with a lot of data on the Massachusetts health care system. From the report we learn that more and more people have health insurance since the reform was put into place. The way people are being covered varies, and the state has a smaller percentage of employees accepting the health care coverage from their employer than other states. It is likely the case that these people have other options such as the state programs, whereas employees in other states do not. This is costing Massachusetts more money to cover these people and may be an area that needs to be reviewed for potential reform. The trend however displayed in the report is an overall increase in coverage on the part of citizens.

This report is a useful snapshot of the outcomes associated with the Massachusetts health reform Act. It provides data on the number of enrollees and the costs associated with the system, as well as a comparison to years past.

Reform around the Globe

10.

Gordon Liu, Zhongyun Zhao, Renhua Cai, Tetsuji Yamada, (2002) Equity in health care access to: Assessing the Urban Health Insurance Reform in China; Social Science Medicine 55 1779-1794.

This article looks at the reform to the health care system in China. The program was piloted in two cities and ultimately was expanded to the entire country. The program had local governments pool their total insurance funds into a single plan. The new plan was funded by two accounts; one for individuals (funded by employees in varying amounts) and by an account for all subscribers. Payments for services draw from the individual accounts, followed by a deductable based on salary and finally from the shared account.[25]

The program sought to control costs through provider participation in fee schedule and government determined reimbursement for services.[26]

Those providers were to be evaluated on a yearly basis.[27]

The analysis looked at outcomes from the reform, finding that access to health services improved for the poor, although disparities still exist. The study concluded that the implementation of the program resulted in a more equitable distribution of primary care services and reduced the cost through utilization of clinics over emergency rooms.[28]

The study revealed a increase however in the disparity between socio economic groups and their access to expensive procedures.[29]

One of the issues with the US system is the disparities between the rich and poor’s access to health care. While China and the US differ in many ways, there it is still possible to learn from one another. This article provides an example of reform and evaluates its success and failures. The article has an extensive reference section for further information on China’s health care system.

> 11.

The author of this article begins by giving a history of government provided health care in the Thailand. In 1975, the Thailand government began to provide medical coverage through a Medical Welfare Scheme (MWS) to the poor.

[30]

The program was expanded to cover children under 12, veterans, community leaders, monks, and the disabled.[31]

Later a Social Security Scheme (SSS)to cover employees in the formal (or government) sector. To compliment these programs a Voluntary Health Card Scheme was introduced in 2000, which was a voluntary publicly subsidized insurance scheme that 70% of people enrolled in.[32]

Finally in 2005, a Universal Coverage Scheme (UCS) was passed in order to incorporate all uninsured persons.[33]

A study was completed to look at the financial impact of the transition to universal health care coverage in Thailand. The study looked at out of pocket expenses pre and post implementation.[34]

The Universal Coverage Scheme along with other afore mentioned programs implemented pre-pay mechanisms in place, which covered health care costs up front.[35]

The study found that out of pocket costs, catastrophic health care payments, and poverty, decreased over this time.[36]

The authors of the study point out that a coordinated effort to reduce poverty by the government also likely played a role in the reduction of poverty rates.

This study provides valuable lessons for systems aiming to reform health care. The author argues the effective reform must address the numbers of people covered by health insurance, but also the catastrophic costs associated with health care. This article has an extensive reference section which includes articles on the Thailand and other countries health reform efforts.

12.

PBS Frontline, Sick Around the World April, 2008.

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries

This program evaluated the health care systems of countries around the world. The program looked at the United Kingdom, Japan, Germany, Taiwan, and Switzerland.

The program begins by looking at United Kingdom who spends 8.3% of its gross national product (GDP) on healthcare. This system is “socialized medicine”, a system where the government both provides and pays for the health care. The system is funded through tax dollars. Because there are no bills, the administrative costs are low. Physicians are rewarded for keeping their patients healthy, an incentive that helps reduce overall costs.

The second system examined by the program was Japan who spends 8% of their GDP on healthcare. Japans program is considered a “social insurance” program. All citizens are required to purchase insurance from a non-profit plan and those who can’t afford the coverage receive public assistance. This system has mostly private insurers and doctors.

Third, is Germany who spends 10.7% of their GDP on health care. Germany is similar to Japan in that they have a social insurance model. Unlike Japan, Germans do not get their insurance from employers, but have many private insurers to choose from. The costs for Germans are much higher than that of the Japanese.

Taiwan is the fourth country reviewed by the program. They recently adopted a “National Health Insurance” plan in which all citizens must have health insurance. There is only one government run insurer and employees split their premiums with their employers. Veterans and the poor are fully subsidized, making the plan similar to the US Medicare program. The program has reduced its cost since implementing the program through initiatives such at the “smart card” which stores patients medical histories and billers the national insurer.

Finally, the program looked at Switzerland whose GDP is 11.6 %. Their program is a social insurance program much like Japan and Germanys’. This form of health care delivery is relatively new, having been voted on in 1994.

This program provided the viewer with a glimpse into other industrialized nations health care systems. While many of the countries vary in their delivery systems they all spend less of the GDP on health care then the US and their citizens spend less on average than US residents. These successes have not gone unnoticed by Americans and many of the proposals in the last election had their foundations in these delivery systems.

[1]

Id. at 62

[2]

Id.

[3]

Id government website

Id at 1452