June 7, 2009

The Long and Winding Road to Health

Posted in Health System Reform tagged , , , at 4:56 am by healthyacrossthenations

In the Early to Mid 1990’s There was a lot of Buzz in the US about how broken the Health System was and there was discussion about possible ways to go about addressng these challenges.

Unfortunately, this was such a novel discussion at the time and many people were uncomfortable. The US system of Health coverage has been historically entrenched with private insurers coordinating with employers or trade organisations if at all.

How fortunate then are we to have since had the experiences in most states across the US of the State Children’s Health Insurance program (SCHIP). This was a program that was funded by both the federal government and the states. Its purpose was to be able to offer basic health coverage to children of mostly working families who were not poor enough to qualify for Medicaid, but were to poor to afford the private health insurance options available. This problem was made worse in the mid to late 1990’s and onward by Economic challenges posed to many companies who responded by lessening or stopping their coverage of employees dependents. The Federal government offered a  list of a few standardized guidelines for the SCHIP program- from which each state could design the SCHIP program that suited them best. SCHIP, like Medicaid- reimbursed existing health Insurance Group Providers.

For example- States could increase the qulaification threshold for families if they felt necessary- ie increasing the mandated percentage over the poverty line that the federal government stipulated for the program. Also- States could use existing Medicaid infrastructure (offices, staff) and expand upon this- or they could develop entirely new infrastructures. Moreover, SCHIP was not a full entitlement program. There was a sliding scale payment system according to the family income. This was just as important for the families as it was for the efficiency of the system (see below).

Even more notable, there was a lot of research done before and during the implementation of SCHIP. One significant finding was that people in this category were less likely to access services consistently if they felt it was an entitlement program- but if they were given an Insurance card that looked like other insurance cards- and they were able to contribute payment – if even on a sliding scale basis- families overall were more likely to consistently access the services. This is a crucial point especially for Children as Preventative and Curative Health Care at the earlier ages are key to preventing serious health issues later on- and thus in order to maintain a future productive segment of the population. Another was that if the Mothers of children were covered by the same insurance provider that the children went to under the SCHIP program- they were more consistently immunized and monitored for health maintenance. As a result, a number of states began to expand coverage to Mothers. Research then showed that Health Maintenance was even better when both parents were covered by the same provider as the kids- and so a few states that felt they could expanded further.

Today there is much discussion about offering Universal Health Coverage n the US. There are serious problems of lack of coverage, and as a result an overburden on Hospital emergency rooms as people wait too long to receive regular care. This is bad for patients, and bad for the economy as Emergency Room visits are very costly and the hospital and/or state end up paying! Moreover, the overall health of the population is beginning to decline due to inadequate access to care and prevention. This lessens the likelihood of  younger people being able to be as productive in later life as they might have been with proper access to care.  So too it is that if adults must wait until they go to the hospital in emergency condition in order to seek care- they will likely have had a lower productivity at home and at work leading up to this- and will certainly have to stay in hospital at least a day thereby foregoing more productive work and home hours as a result of poor or no access to care. If the move to a more humane and inclusive Health System is not handled gingerly and in a fluid manner- there could be a collapse of infrastructure on many levels.

The recent questions put to the House of Representatives committee from the public regarding a single payer system are good questions. However, having lived in the UK and experienced both the positives and negatives of the Single Payer and single provider system- I can say that the UK has been doing this for a long time- their constituents have become habituated to this system- and still there are a number of challenges and there are always new tweaks and ideas.

The US has the experience of Medicaid and SCHIP to work forward from.

One idea might be similar to what some European countries (France) – and Israel-  have been doing for some time. This is the continued use of a number of existing Health Insurance companies- which perhaps may be called Health Funds. They would have to accept all candidates for coverage that applied and would submit to the federal and state governments a list of the number of people they cover- their ages and for certan health conditions. The government would then use a Mathematical capitation  formula to determine the amount of money it will provide to each of these Health Funds, money that they might raise from employer contributions, client dues paid on a sliding scale according to income  and other value added services (Israel receives employer contribution which constitute up to 30% of national expenditure and Clients pay dues on a sliding scale according to income) . Funding the Health Funds according to the ages, health and numbers of clients they have.
This will encourage the Funds to indeed accept candidates- and to compete with other health funds to provide quality service.  In order to ensure the efficiency of the System, there would be a small co-payment to see specialists and other auxilliary Health Personnel- about $2-$4. This would not be a large deterrent for people if they needed to see a specialist- but would be a deterrent for wasteful referrals- and yet would enhance the economic well being of Doctors and/or  Health Funds.

In order to diversify service provision and balance crowding concerns at the basic level of care, these basic plans could be supplemented to offer higher levels of service for a small fee- perhaps about $10-$15 a month. This level might include Alternative Health Coverage including a certan amount of Physiotherapy sessions- managed by the Health fund- and emergency coverage in other countries (This is done n Israel and a few of the European Countries). Other ideas might be for Family clinics to offer moderate membership fees – perhaps $6-$8 a month- that would go straight to the Clinic for staff and supplies- and could offer a higher level of customer service to those clients (This is a much better idea- and so much more practical -as it is clinic based and not doctor based-for a larger number of people than the extraordinarily expensive VIP service now being offered in the US) .

These ideas are not new- and they offer a basic level of Health Care as well as presenting opportunities for people to moderately supplement their plans if they would like to or need to for any reason. This keeps an element of personal private coverage and investment- along with a universal basic coverage.

There is thought that the extra cash going to the Health Funds can help provide better service overall- if not to at least be able to maintain a certain quality of care (research is still being done about this fact- but this is the idea).

I do not believe that moving directly to a single payer single provider system at this point in time would be good for the US.  I think Health Policy Planners need to carefully look at other Health Systems to get an idea of what elements might be the best for the US to adopt at this point. Canada has an interesting system based on a single payer but with private provision, as do the Netherlands- which a few years ago began to encourage those who could afford private insurance to do so), Israel and more. Switzerland has too high a gap between basic coverage- which is quite poor and does not seem to benefit much from the Private client subsidies to the Health Funds, and between the very expensive Prvate supplements to coverage.

At the end of the day- we want a more inclusive, humane health care system that can offer basic health care services to the public. We want this not only for humane reasons- but also for economic reasons. Healthier people do not miss days of work or school- they tend to be more productive and therefore will have more to contribute to the nation by way of taxes and more. This in turn is good towards the economic development of our communities,  states, and the whole of the US.



  1. healthyacrossthenations said,

    Here is an article from 1994 that Shows the earlier attempts at the discussion of Health Care Reform:


  2. healthyacrossthenations said,

    Here is a more recent article about President Obama’s push for more inclusive coverage- and while he may not yet have the How’s- that is something we can all work on:


  3. healthyacrossthenations said,

    Even Senator Kenedy Weighs in complementing some of the ideas mentioned above:

    “Senator Edward M. Kennedy, the ailing champion of health care issues, has drafted his own sweeping bill. Under the plan, The Times’s Robert Pear writes, “all Americans would have access to ‘essential health care benefits,’ with no annual or lifetime limits, employers would have to contribute to the cost of coverage and the government would create a new public insurance program.”


  4. healthyacrossthenations said,

    It is important to note that in Israel, only 8.2% of GDP in 2000- and this is much lower than the current (2008) US Expenditure of 17% of GDP!!!!!

    Israel’s Health System


  5. healthyacrossthenations said,

    Paul Krugman of the NY Times also notes that The French Health System spends half or less percentage of GDP as does the US on its Health Care System.

    France has a very interesting system indeed- it’s Statutory Insurance is offered along professional/career lines and has a section for the self employed as well.


  6. healthyacrossthenations said,

    Here is a wonderful NY Times Blog discussion about Health Coverage and whether it should be mandatory:


  7. healthyacrossthenations said,

    Here is a great and recent article from the Economist about US Health Care Reform:


    It talks about runaway health inflation over the last decade, why adopting the Netherlands Plan in its current form would be a bad idea- as Even the Netherlands started out with mandatory nsurance for all- and still does- but recently began letting wealthyier people supleent with private insurance.

    This is a great article.

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