Statement of the Problem: Health Reform, Value-Based Purchasing, Alternative Payment Strategies, and Children and Youth With Special Health Care Needs.

There is increasing interest in maximizing health care purchasing value by emphasizing strategies that promote cost-effectiveness while achieving optimal health outcomes. These value-based purchasing (VBP) strategies have largely focused on adult health, and little is known about the impact of VBP program development and implementation on children, especially children and youth with special health care needs (CYSHCN). With the increasing emphasis on VBP, policymakers must critically analyze the potential impact of VBP for CYSCHN, because this group of children, by definition, uses more health care services than other children and inevitably incurs higher per person costs. We provide a history and definition of VBP and insurance design, noting its origin in employer-sponsored health insurance, and discuss various financing and payment strategies that may be pursued under a VBP framework. The relevance of these approaches for CYSHCN is discussed, and recommendations for next steps are provided. There is considerable work to be done if VBP strategies are to be applied to CYSHCN. Issues include the low prevalence of specific special health care need conditions, how to factor in a life course perspective, in which investments in children's health pay off over a long period of time, the marginal savings that may or may not accrue, the increased risk of family financial hardship, and the potential to exacerbate existing inequities across race, class, ethnicity, functional status, and other social determinants of health.

Looking Under the Hood of the Cadillac Tax.

One effect of the Affordable Care Act's "Cadillac tax" (now delayed until 2020) is to undo part of the existing federal tax preference for employer-sponsored insurance. The specific features of this tax on high-cost health plans--notably, the inclusion of tax-favored savings vehicles such as health savings accounts (HSAs) in the formula for determining who is subject to the tax--are designed primarily to maximize revenue and minimize coverage disruptions, not to reduce health spending. Thus, at least initially, these savings accounts, rather than enrollee cost-sharing or other plan features, are likely to be affected most by the tax as employers act to limit their HSA contributions. Because high earners are the ones benefiting most from tax-preferred accounts, the high-cost plan tax will probably be more progressive than prior analyses have suggested, while having only a modest impact on total health spending.

The evolution of dependent medical care in the U.S. Army.

There is great focus within the military medical community regarding the ever growing cost of medical care overall and dependent care specifically. A great deal of discussion relates to the delivery of care through a growing military-civilian partnership, where an increased amount of health care will be referred to an ever growing network of civilian providers. The U.S. military establishment now stands at an important crossroad leading into the future of dependent care. However, the special concerns, which arise from the responsibility of caring for military dependents, are not a solely recent phenomenon. Ever since the establishment of a permanent standing U.S. Army in the late 1700s, there have been families in need of medical treatment. Although changes occurred continuously, the development and evolution of policies regulating the delivery of medical care to dependants can be divided into three periods. The first is the longest and ranges from the establishment of the Army until the year 1900. The second period spans from 1900 to the post-Korean War year of 1956. The third and final period is from 1956 to 1975. Special changes and advances in each of these periods have served to shape the face of dependent care in today's Army Medical Department.

The redistributional impact of Canada's Employment Insurance Program, 1992­2002.

For a decade or so starting in the early 1990s, Canada's major income support programs underwent substantial reform. Meanwhile, the economy first lingered in a deep recession and then recovered with a period of strong growth. This paper focuses on how the distributional impact of Employment Insurance (EI) evolved during this period. We find that EI was strongly redistributive throughout the whole period with respect to the earnings of individuals, and somewhat less so for family income. But we also show that the distribution of benefits and contributions changed substantially over time, becoming less redistributive. Somewhat counter-intuitively, both the benefit and contribution sides of the program are shown to be redistributive, even though the contribution structure is regressive. These findings are relevant in the current context, as the economy struggles with a combination of high unemployment and fiscal pressures on government spending.

The struggle over employee benefits: the role of labor in influencing modern health policy.

After organized labor failed to institute national health insurance in the mid-twentieth century, its influence on health care policy diminished even further. This article proposes an alternative interpretation of the development of health care policy in the United States, by examining the association of health policy with the relationships between employers and employees. The social welfare and health insurance systems that resulted were a direct outcome of the pressures brought by organized and unorganized labor movements. The greater dependency created by industrial and demographic changes, conflicts between labor and capital over the political meaning of disease and accidents, and attempts by the political system to mitigate the impending social crisis all helped determine new health policy options.

Impeding Earl Warren: California's health insurance plan that wasn't and what might have been.

It is widely believed that the turning point for U.S. health insurance came in 1949 when Congress failed to adopt President Harry Truman's proposal for a national system. The possibility that a system of state-level health plans might have emerged before Truman's plan has received little attention. Yet several attempts to enact such a plan were made in California by Governor Earl Warren in the mid-1940s. Had Warren succeeded, the California example might have been emulated by other states and the United States might have evolved a system similar to Canada's provincial programs.

The history of employment-based health insurance: the role of managed care.

The author describes the history of how the employment-based health benefits system has evolved. Specifically, he examines how we got where we are today, the success of managed care, the shortcomings of the managed care system and challenges that the managed care system will face in the future. He concludes that, despite substantial improvements in the quality of medical services provided, employers have a long way to go before they are truly purchasing the highest quality health care at the most efficient prices.

Plan moderno de asistencia a los alienados (1926)

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