The View from Here
Some Unanswered
Questions on the Road to
2017年2月25日
Health Care Reform
As last year’s grueling and contentious presidential campaign fades into memory, concerned citizens and policy pundits have turned their attention to President Barack Obama’s policy priorities and legislative agenda.While the president has declared that our economic crisis and energy inde-pendence through alternative fuel technolo-gies will be his top priorities,health care reform may not lag far behind.Indeed,the appointment of Tom Daschle as cretary of health and human rvices is widely viewed as an indication that the Obama adminis-tration also will move aggressively on health care reform.
During the campaign,the two presidential candidates offered distinct visions of a reformed health insurance market and health care delivery system.Sen.John McCain’s health care proposal emphasized reliance on voluntary enrollment;deregulation of state insurance markets and sanctioning
of inter-state purchasing of health insurance;creation of subsidized,state-specific‘‘guaranteed ac-cess plans’’for individuals denied health coverage;and replacement of the tax deduc-tion for employment-bad coverage with tax credits for individuals and families.The key provisions were expected to promote greater individual choice among health plans,more competition among insurers,and incread cost consciousness by consumers,thereby spurring incread enrollment and cost sav-ings.By contrast,the Obama campaign offered a health reform approach that would build on current state health insurance regulatory structures;mandate coverage for children;impo a‘‘play or pay’’mandate on large employers(but also leave the door open for an individual mandate);eliminate risk rating from health insurance premiums;and expand income-eligibility thresholds for pub-lic coverage,among other provisions.
While at times the candidates engaged in overreaching rhetoric to persuade voters of the advantages of their proposals,each plan reprented an incomplete map of the road to reform and,thus,was noteworthy for what was not addresd.In anticipating the health care reform debate to be stimulated by an Obama administration,it is both instructive and sobering to consider some of the unaddresd issues.I want to highlight four such issues that I view as particularly salient. How Will We Meet the Long-Term Care Needs of a Growing Elderly Population? Perhaps one of the more
glaring omissions of the presidential campaign was a rious discussion of how to provide and finance the long-term care needs of a growing elderly population,many of whom will require admission to nursing homes or formal and informal care at home.While the popula-tion’s long-term care needs have been ne-glected in previous health reform initiatives and left to the province of state Medicaid programs,private savings,and a nascent private long-term care insurance market,this issue will become particularly acute as the current generation of baby boomers ages and, more generally,as life expectancy expands. Projections reported by the Government Accountability Office(U.S.GAO2005) suggest that by the year2020,the percentage of people age65or older will increa by a third(from12.4%to16.3%),and by2040the percentage of people age85and older (reprenting tho most in need of long-term care)will increa by250%(from4.3million to15.4million people).Additionally,by
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2040,the disabled elderly are projected to grow by a third to two times their current levels.While cost
estimates over such an extended period are likely to be impreci,the GAO report cites projections by the Con-gressional Budget Office that by2040,long-term care expenditures could exceed two-and-one-half times their2000levels,straining federal and state programs such as Medicaid that also provide care to the nonelderly poor. The long-term projections suggest that an increasing share of our health care resources will be required to support the health care needs of a growing and increasingly frail elderly popula-tion.Correspondingly,the demands on both formal and informal home care also will ri, putting additional pressure on public budgets and personal resources,and compromising the time commitments and labor supply activities of family caregivers.The impact on families will be particularly stressful,given the continuing economic need for both spous to work and the additional demands placed on families who care for their own children or grandchildren.
As a final point,the demand-side issues also will rai concerns about the supply of high-quality institutionalized long-term care rvices.For example,the Department of Health and Human Services recently reported that in2007,94%of all nursing homes were in violation of federal health and safety standards(Pear2008).At the same time,the growing complexity of ownership responsi-bility for private nursing homes(who authority has been obscured through legal maneuvering much the way that the owner-ship of home mortgages has been parceled into collateralized mortgage obligations)h
as made it increasingly difficult for families to ek redress for substandard care provided to their elderly parents and relatives.While health care reform will have many demands on the table,it is certainly not too early to consider the trade-offs that will be necessary to meet the growing need for long-term care. Can We Obtain Meaningful Coverage Expansions without First Addressing
Cost Containment?展台英文
In a plenary address delivered this past June to the American Society of Health Econo-mists,Mark McClellan,former administrator of the Centers for Medicare and Medicaid Services and prently at the Brookings Institution,expresd the view that cost containment is a necessary prerequisite for meaningful insurance expansions.While it is unlikely that we will have the patience to delay coverage expansions until the cost-containment puzzle is solved,McClellan’s point was nevertheless a sharp reminder that failure to control costs could jeopardize any real prospect for significant reform.This point was raid earlier in the year by Ezekiel Emmanuel(2008)who,noting that rising health care costs are associated with higher uninsured levels,applied the mantra of Bill Clinton’s2002campaign to health care in an article subtitled,‘‘It’s Health Care Costs, Stupid.’’Emmanuel took a more measured approach than McClellan,arguing that cost containment and coverage expansions need not occur quentially,but could move forward simultaneously.
Regardless of your perspective on how reform should unfold,cost containment remains‘‘the elephant in the room.’’Both the McCain and Obama campaigns cited interventions such as the u of information technologies,pay-for-performance provider incentives,technology asssment,and more preventive care as among the ways to contain exploding health care costs.Additionally,key Obama health advirs relead a memo asrting that the application of information technology,better dia management,re-duced insurance administrative costs,and the application of clinical effectiveness rearch and performance payments would reduce health insurance premiums by$2,500for a typical family,thereby making coverage more affordable.
In thinking about the necessity of cost containment and prospective cost savings,it is important to have realistic expectations as to how much can be achieved in the short run as the parameters of reform are defined and fine-tuned.Bad on other recent and past reform initiatives,both projected savings and reform plan costs are likely to be optimistic and perhaps illusory.In writing about health reform cost projections for the The New York Times,Kevin Sack(2008)interviewed veral
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health economists who noted the uncertainty inherent in obtaining reliable estimates of the cost savings from candidates’health reform proposals.
More specifically,the savings expected from implementation of measures such as preventive health care,adoption of informa-tion technology,and incentive-bad perfor-mance measures may be less than expected when broadly applied.For example,some ,Cohen,Neumann,and Wein-stein2008;Rusll2007)have questioned the claim that prevention uniformly will save costs,noting that savings will depend on the type of intervention and that prevention frequently adds more to costs than it saves. The application of information technologies may require upfront investments in equip-ment,software,and education before yielding returns,and smaller provider practices may be unable to afford the initial start-up costs. Finally,incentive-bad interventions such as pay-for-performance(P4P)may produce un-intended effects as providers ek to comply with performance standards.For example, Sandeep Juhar(2008)has noted that P4P may yield a number of perver respons by providers including:cherry-picking patients who are able to comply with treatment; pressure to apply performance standards to patients without a firm diagnosis;disincen-tives to innovate or improve outcomes by departing from the treatment standards; difficulty assigning responsibility for treat-ment when veral physicians are providing care;and incentives to comply with standards by prescribing medications that may yield few net benefits.Conquently,the relationship among expected savings from such interven-tions,our ability to accurately project plan costs,and ultimately,the scope of health reform bear clo scrutiny.
Can Smart Regulation Spur
Smart Competition?
Calls for more widespread and vigorous regulation of financial transactions and banking practices have emerged in reaction to the current meltdown of our financial markets and lending institutions.In respon to the prescriptions,some obrvers have urged restraint,asrting that‘‘smart regula-tion’’is esntial to avoid compromising the efficiencies and innovations inherent in com-petitive financial markets.The same could be said for regulation of our health insurance markets.Empirical evidence indicates that some regulatory interventions have produced unintended conquences that have changed the risk composition of the market and,as a conquence,have reinforced incentives for insurers to compete through favorable risk lection rather than through health plan costs and quality.
In this regard,the ability to recognize when regulatory provisions may be counterproduc-tive and to have the flexibility to alter such interventions to improve the function-ing of markets is critical.My own state of New Jery provides a uful example of the willingness of legislators to adjust insur-ance market rules in a way that is consistent with obrved experience and available re-arch.Specificall
y,individual health care coverage in New Jery is obtained through the Individual Health Coverage Program (IHCP),which provides for the guaranteed issue of health plans and pure community rating,among other provisions.As rearch has disclod(Monheit et al.2004),a few years after its1993implementation,the IHCP experienced a precipitous decline in enroll-ment,a corresponding ri in premiums (especially for its most generous health plan), and a shift to older and less healthy enrollees. Whether such trends were consistent with an adver lection spiral remains unresolved since both economic and institutional changes also were taking place in New Jery and its insurance markets.However,it became ap-parent to regulators and legislators that unless changes were implemented,a sustain-able individual market was in grave jeopardy. In health reform legislation enacted in July 2008(New Jery Senate Bill#1557),specific provisions were included to alter premium regulations in an effort to bolster enrollment in the IHCP by attracting younger and healthier enrollees.Pure community rating of premiums was replaced by risk-adjusted premiums bad on an enrollee’s age,and the range of acceptable premiums was con-strained by rate bands.Recognizing that the
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change to age-adjusted premiums would subject older enrollees to premium increas, the state limited premium increas to no more than15%over the ensuing four years. While it remains to be en whether the change to risk-adjusted premiums will lead to improved enrollment in New Jery’s IHCP and a more efficient and competitive market-place,the state’s reaction provides a uful example of what I would characterize as ‘‘smart reform’’:the importance of recogniz-ing when a championed principle of reform is not working or is yielding unintended con-quences,and the willingness to compromi and take remedial action.At the same time, making the change to risk-adjusted premiums may reduce incentives by insurers to favor-ably risk lect as premiums more appropri-ately reflect enrollee health risks.
五年级英语下册教学计划Will Health Care Reform Achieve Greater Intergenerational Equity?
As has been reported in numerous academic studies and in the popular press,the prent generation of recent college graduates and young adults faces vere economic challeng-es.Saddled with sizable educational debts, participating in labor markets characterized by sustained periods of stagnant earnings growth,and facing great uncertainty regard-ing short-and long-term employment pros-pects,the economic status and curity of the young workers is unlikely to surpass that of their parents.At the same time, younger workers bear an increasing burden of financi
ng the retirement and medical care benefits for an aging population as depen-dency ratios(the ratio of elderly to nonelderly people)ri,and as the number of workers per Medicare beneficiary declines.
The trends in economic curity and financial burden have been accompanied by a perceived imbalance in health care and other public resource allocations between the elderly and nonelderly.Over the last two decades,the ratio of per capita health spending on behalf of the elderly has been more than three times that of the working-age population,and more than five times that of children(Hartman et al.2007).This imbal-ance in resource allocation has perhaps been most profound for the Medicaid program, where in2005payments for children averaged $1,617compared to$11,839for the elderly (Kair Family Foundation2008).Such disparities and young people’s growing finan-cial burden have raid the basic issue of fairness or intergenerational equity.This has caud some obrvers to reconsider how health care resources should be allocated among different generations.For example, Alan Williams(1999and elwhere)has argued that each generation is entitled to its ‘‘fair innings’’—an agreed-upon normal life span defined in quality-adjusted life years—and extensions beyond this period by older people should not be made at the expen of younger individuals who have not yet at-tained this standard.In a somewhat more extreme reaction to such equity concerns, Isabel Sawhill and Emily Monea(2008)have advocated re
working the intergenerational contract so that the flow of resources to older generations is constrained and directed more toward young families and children.
Health care reform that encompass a broad coverage expansion is likely to confront the intergenerational equity prob-lem head-on.By adding45million children and adults to public and private health insurance,policymakers will have commit-ted resources to meet the health care needs of the nonelderly.Unless we are willing to have health care absorb an even larger share of our nation’s output,policymakers will be required to asss the relative payoff to health care resources spent on each of the groups.Although the burden of financing care for older Americans will remain largely the responsibility of the young,health reform may effectuate a realignment of health care resources,a reasssment of our health care priorities,and a healthy debate over the fairness of intergenerational resource disparities.
staff什么意思Conclusion
In its formulation and implementation,sub-stantive health reform will confront many difficult issues.It is certainly not too early to acknowledge and anticipate the compelling economic,regulatory,and equity issues that
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will likely drive the policy debate.By explicitly acknowledging that limited resourc-es may constrain the scope of health care reform,that trade-offs among objectives must be made,and that priorities must be estab-lished,policymakers stand a better chance of enlisting public support and achieving mean-ingful reform.
Alan C.Monheit,Ph.D.
Editor
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怎么报名什么时候报名
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