The VA health care system: an unrecognized national safety net.

The dominance of local health care markets in conjunction with variable public funding results in a national patchwork of "safety nets" and beneficiaries in the United States rather than a uniform system. This DataWatch describes how the recently reorganized Department of Veterans Affairs serves as a coordinated, national safety-net provider and characterizes the veterans who are not supported by the market-based system.

The politics and economics of mental health 'parity' laws.

The enactment of the Domenici-Wellstone amendment in September 1996, which calls for the elimination of certain limits on coverage for mental health care under private insurance, is being hailed as a major step forward in the quest for "parity" in mental health coverage. Parity legislation is being introduced in a number of state legislatures and is finding new enthusiasm in Congress. In this paper we consider the efficiency rationale for these laws and examine their likely impact in the era of managed care. We conclude that although such successes represent important political events, they may offer only small gains in the efficiency and fairness of insurance markets.

The Clinton plan: what happened to the tough choices?

This paper points out four difficult choices embedded in the Clinton plan. First, universal coverage is achieved, but with regressive head-tax financing on many workers-since the cost of the employer mandate ultimately will fall on workers' wages. Perhaps such an approach can be made politically acceptable. Second, cost containment is entrusted to global spending limits, which will limit the rate of improvement in quality. Third, the offering of choice among a variety of health plans of different costs and quality, although desirable in itself, may lead to inequity. Finally, the plan's financing will make it difficult for voters to tell what trade-offs they are making, because employer mandates and budget cuts disguise choices.

State initiatives for the medically uninsured.

Recently, Medicaid has changed in terms of both perception and reality. After a period of decline in entitlement, that trend has been reversed through both Federal mandates and an increasing role for Medicaid in dealing with the uninsured. As States and the Federal Government seek structural solutions, further eligibility expansions may be necessary, such as public subsidies of private insurance of using Medicaid as a reinsurance mechanism. Currently, there is considerable State activity in identifying such solutions. These activities have given us some ideas about what is necessary to expand coverage to more of the population. Continued demonstrations and better definitions of the respective roles of the private and public sectors are needed.

Medicaid, the uninsured, and national health spending: federal policy implications.

Implications are discussed for Federal policy of "gap-filling" initiatives at the State and Federal level to deal with the problem of the uninsured. Measures currently under active consideration that involve expansions of Medicaid and employment-related insurance are considered in the light of recent studies of the uninsured and recent simulations of their cost and coverage impacts. The limited impact of these gap-filling measures on additional national health spending, in contrast to program costs and Federal outlays, is emphasized. Placing greater emphasis on this broader societal perspective could assist Federal policymakers in developing an acceptable strategy for covering the uninsured.

Health care reform and the role of public health agencies.

Experience in developing a local public health program, covering a period of approximately 45 years, is described. Included are the assessment and analysis of problems, policy formulation, plan development, and program implementation. A study of problems of seasonal farm workers, particularly those who migrate, is described, as well as a health services delivery program based on this study. Attention is given to incorporation of medical care with core public health services, and the use of a multidisciplinary team. Special features required to overcome cultural, language, educational, and other barriers are outlined. Adaption of knowledge gained from the migrant health project toward meeting needs of the county's medically underserved population is described. Involvement of the community, including representatives of private and public sectors, in the development and implementation of plans is emphasized. Maintaining appropriate emphasis on preventive aspects is discussed, together with mobilization of financial and other support. The importance of qualified public health staff is also emphasized: residency programs for physicians and dentists and training for other personnel are described.

Delivering breast and cervical cancer screening services to underserved women: Part II. Implications for policy.

Many breast and cervical cancer screening (BCCS) programs for underserved women employ strategies to increase the use of preventive services. In Phase I of a two-phase study, strategies were identified and assessed. In Phase II, we further assess strategies previously identified and comment on policy implications. Site visits were conducted at BCCS programs that had used one successful strategy identified during Phase I, provided services to underserved women, and were located in different geographic regions. The federally funded National Breast and Cervical Cancer Early Detection Programs (NBCCEDP) were also considered for site visits. Interviews were completed and available data were reviewed. A descriptive and qualitative analysis was completed. Programs visited were found to be increasing the use of BCCS services for the defined target populations. Some programs focused on outreach and recruitment. Other programs focused on clinical preventive services with little emphasis on outreach and recruitment. Management information systems were used by most programs. We found that there continues to be a large number of women not receiving BCCS services. Some programs have had to limit outreach and recruitment because the clinical preventive services offered are at capacity. Programs need to have a balanced approach to providing services from the outset. Existing programs may need to establish partnerships to provide comprehensive BCCS services to underserved women. Because the unmet need (women who have not received BCCS services) exceeds available clinical preventive services, it is a challenge to know how to best use available resources.

Costs and distributional impacts of employer health insurance mandates and Medicaid expansion.

A large number of Americans are uninsured. A number of recent proposals have been developed to extend coverage to the 31 to 37 million individuals currently without health insurance. This article examines two recent proposals. The first is to mandate coverage through the workplace. Two different methods of mandating workplace coverage are explored: the recent Kennedy-Waxman bill and the approach adopted in Massachusetts. Although both approaches cover the same number of uninsured, both the aggregate costs and their distribution differ dramatically. The article also explores the coverage and cost implications of an expansion of Medicaid alone and in conjunction with the employer mandate options.

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Because no national health program assures entitlement to basic services, advocates must cope with barriers to access on the local level. The authors report several strategies that a community-based coalition has used to improve indigent care in one county. Research strategies have involved short-term investigations of barriers to needed services. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor. Legal strategies have involved the participation of attorneys who represent clients unable to receive care. Although such advocacy efforts do not guarantee access, they can substantially improve the availability of local services.

Portrait of inequality.

America's children are stalked by race- and income-based inequities that demand our attention. Health care reform efforts that respect the needs of the entire child can diminish these inequities. Six prescriptions will help: universal early childhood education; comprehensive health and family life education; parental support; reinforcement of male responsibility; comprehensive school-based clinics; and opportunities for higher education.

Health care for Nebraska's medically indigent.

In this study, several alternatives for the provision of health care to the medically indigent of Nebraska were analyzed quantitatively and qualitatively. These alternatives were: expansion of county medical assistance programs, state-purchased health insurance policies, Medicaid expansion, revenue pool to redistribute charity-care losses, all-payer rate system, mandated employer-purchased health insurance, and charity-care districts. Under four future scenarios, alternatives were ranked on the basis of program costs, a sensitivity analysis, and qualitative criteria. This analysis found that state-purchased health policies would result in lower program costs than either an increase in county assistance programs or employer-mandated health insurance. Medicaid expansion would reach fewer than one-third of the state's medically indigent. A revenue pool and all-payer rate system are the least costly alternatives but depend on the continuing good will of providers.

The Oregon Health Plan: a rational approach to care for the underserved.

The Oregon Health Plan addresses the needs of 450,000 Oregonians presently without health insurance, among them 120,000 living in poverty who are not now Medicaid-eligible. This is accomplished by expanding eligibility for Medicaid to individuals and families with incomes at 100 percent of the federal poverty level. T0 help expand access within the limitations of the state budget, certain services, determined to be of limited value or effectiveness, are not covered for payment. This concept of rationing health care reimbursement stands in contrast to existing mechanisms of rationing employed by every state and the nation. The Oregon Health Plan introduces a rational plan for expanding services to the entire population of the state, while acknowledging the limitations of funding resources.

Hawaii's near-universal health insurance--lessons learned.

To date, Hawaii is the only state to have implemented near-universal health insurance. The cornerstone of this program is the country's only requirement that employers provide health insurance for all employees who work at least 20 hours per week. Combined with low unemployment, voluntary modified community rating by health insurers, and expanded Medicaid and Medicare, this employer mandate has been part of a patchwork mechanism that insures upwards to 95 percent of the state's population. Indeed, by adding a state-sponsored gap group-insurance program, Hawaii may now insure in excess of 95 percent of its population. The program has generated good health outcomes, good consumer satisfaction, and relatively modest overall health care expenditures. But for all that near-universal insurance provides, there is still a great need for community-based preventive and primary care programs with outreach and family support services. In addition, traditionally underserved populations continue to be at increased risk. Both funding reform and continued infrastructure development must occur to achieve universal access to care.

Can a poor state afford not to expand Medicaid?

Some advocates of the uninsured support expansion of Medicaid programs, while others say that expansions are simply unaffordable, especially in poor states. State-level analyses of the costs and consequences of these expansion programs are infrequent. This study evaluates three programs to expand eligibility for Alabama's Medicaid program. The first two programs would raise the Aid to Families with Dependent Children (AFDC) eligibility threshold to 50 and 100 percent, respectively, of the federal poverty level. The third program, currently not available to the states without a federal waiver, would drop all categorical eligibility requirements and base eligibility solely on whether income is below the federal poverty level. Only 10.7 and 18.3 percent, respectively, of Alabama's uninsured would gain health care coverage under the first two programs. The third program would increase the proportion of Alabamians with health coverage to nearly 50 percent. For all of these programs, front-end state costs would be largely countered by federal funding and offsets, such as reductions in uncompensated hospital care and savings realized by former uninsureds from reductions in out-of-pocket expenditures for health services.

How Tennessee finances Medicaid.

Tennessee is fortunate to have a comprehensive Medicaid program involving some 22 optional services, all financed through a combination of state revenues. These range from general state revenues to provider-donated funds, provider-specific taxes, and recently, a privilege tax. The state pays approximately $920 million to participate in Medicaid; the state's share generates $1.9 billion in federal dollars. The current system for financing the state's Medicaid program is unsustainable. Because Tennessee is relatively poor, legislators cannot afford to continue to increase its share of Medicaid expenditures at a rate 10 times greater than the general revenue increase from the entire state. To continue a comprehensive Medicaid program, Tennessee must move forward with alternative strategies to control Medicaid expenditures and manage resources.

Managed health care for Medicaid enrollees: the Philadelphia model.

HealthPASS, a program of capitated managed care for 82,000 Medicaid enrollees in a defined geographic area of Philadelphia, Pennsylvania, is administered by Healthcare Management Alternatives, Inc. (HMA), a minority-owned corporation, under a multiyear contract with the Commonwealth of Pennsylvania. HMA has striven to improve care to this low-income community by mounting innovative campaigns to encourage early access to health care, ongoing health education, and aggressive outreach and follow-up, in addition to specific projects designed to reduce infant mortality, expand Head Start, and bolster pediatric care. The program has been judged independently to provide high-quality service cost-effectively.