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HEALTH CARE SERVICES: OPTIONS ON HEALTH INSURANCE
The United States and South Africa are currently the only industrialized nations that do not have a national health program that guarantees all citizens access to at least a basic set of health benefits. The United States has seen four major political movements supporting national health insurance during the twentieth century, but none has succeeded. Whether universal coverage will - or should - be achieved soon and through what mechanism are hotly debated topics. Many analysts believe that the recent push for health care reform failed due to a combination of circumstances and influences: lobbying efforts by the insurance industry and the medical community; a proposed plan that was too complicated; and interest groups who felt that the plan either went \"too far\" or \"not far enough.\" But some people also believe that our current system serves people well.
One critical point must be made, though, and that is that we are paying for the most expensive system in the world without obtaining full coverage. We pay for people who don\'t have insurance through cost shifting that increases premiums and taxes, and we are paying more than necessary because prevention and early treatment in appropriate settings are not emphasized. We also pay for much duplication of services and technologies, for practitioners who practice defensive medicine and who refer patients to their own diagnostic labs for profit reasons, and for the vast bureaucracy made inevitable by having over 1,500 private health insurance companies.
The managed competition model proposed early in the Clinton administration was essentially based on an employer mandate whereby employers and the major insurance companies would still play a central role. This had appeal\" for those who don\'t wish to change the structure of the system radically or to place a great deal of power in the hands of one institution but do want to do more than merely provide incentives through the tax system. It did not appeal to those who believe that a system based on competition actually fuels costs and increases the emphasis on high technology while leaving the sickest and poorest at a severe disadvantage.
Another proposal involves the federalization and incremental expansion of Medicaid. The idea is to eliminate state disparities and improve coverage gradually through progressive general tax financing. First would come federalization of Medicaid eligibility, benefits, and reimbursement to improve access for those determined eligible. Next would come a step-by-step expansion raising the age limits for children, then covering all pregnant women, then allowing \"intact\" poor families to obtain coverage, then increasing the income limit to incorporate the uninsured near-poor, and finally allowing the middle class to buy into the program. This type of plan could work well if reimbursements were set high enough to encourage provider participation. But it would take a long time to provide universal coverage, and it is not a likely option at this time.
Either managed competition/employer mandate or Medicaid expansion could evolve into a single-payer, tax-financed scheme that severs insurance ties from employment. This type of health insurance mechanism, perhaps similar to the Canadian model, would cover everyone - regardless of income or other factors such as health status. Even this plan would offer many different ways to tailor a plan specifically to the needs of the U.S. citizenry. A single federal plan or a privately administered plan paid for by general tax funds or earmarked taxes could be created. Thus, all (or most) private insurers would be eliminated or would see their role limited to that of fiscal administrators. Benefits would be comprehensive and provide incentives for cost-effective care. In addition, benefits would be \"portable\": they would remain in effect when individuals changed jobs or moved to a different area of the country. Freedom of choice in terms of providers might actually improve in a single-payer system, given how restrictive our current private health insurance system has become. Such a plan would allow far greater control over resource and personnel planning, would improve access to preventive services, and could eliminate duplicate services and technology. Researchers have estimated that adopting a single-payer system would save upward of 120 billion dollars annually in administrative costs - enough to provide coverage to all uninsured Americans. Claims that the Canadian system has long waiting lists have either proved entirely untrue or exaggerated: modest waits did not result in any reduction of health status.
Given the delay in realizing national health care reform, several states have sought ways both to contain costs and to improve access for their populations. Currently, Congress is grappling with several strategies for bolstering Social Security and Medicare.
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GENERAL HEALTH
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