Medicaid and National Health Care Reform

This article provides a brief history of Medicaid, and examines the proposal to restructure Medicaid under health care reform. The author maintains that Medicaid needs to be able to work toward improving the underlying health care system and to integrate these efforts with those expected of exchange insurers. She suggests investments in facilities, workforce, health information technology, and quality-improvement strategies, and the joint development of high-quality provider networks so that care remains stable even as slight income fluctuations expose millions of low-income persons to the risk of frequent shifts between Medicaid and exchange coverage.

Making Health Care Better

This article presents a case study of evidence based medicine, contrasting it with the historical role of intuition in the practice of medicine. The article highlights the experience of Dr. Brent James at Intermountain hospital in Salt Lake City, Utah. While it notes that there is a current debate between intuition and empiricism, the article focuses on the of power of the healthcare quality improvement process — including the use of of various surgery protocols, data review and adjusting care, guideline development, and physician education. This article highlights the role that phsyicians and providers are taking in health care reform, independent of national healthcare reform policies.

Individual Insurance: Health Insurers Try to Tap Potential Market Growth

To examine insurers' strategies in the individual market, information was collected from the 12 communities followed by HSC since 1996 - Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Between August and December 2008, researchers conducted 72 interviews with one to three insurance executives and an insurance broker in each community, along with a representative from the state insurance commissioner's office. Additional interviews were conducted with representatives of state health plan associations, consumer advocacy organizations, national health plans and national associations representing the insurance industry and insurance brokers. This research brief highlights findings from these communities. Overall, national health reform could radically transform the individual insurance market. Current reform proposals include subsidies for lower- and moderate-income people to buy insurance, creation of insurance exchanges and much stricter regulation of the individual market. Proposed regulatory changes include a mandate for individuals to be covered, guaranteed-issue requirements, a ban on medical underwriting, use of modified community rating, which prohibits using a person's health status to set premiums but allows other factors such as age and gender to affect premiums, and products standardized by actuarial value, or the covered medical expenses estimated to be paid by the insurer. For insurers, the mandate requiring individuals to purchase insurance would be key to protecting against adverse selection.

Controlling U.S. Health Care Spending: Separating Promising from Unpromising Approaches

To achieve the goal of constraining increases in health care spending to the rate of growth in the gross domestic product (GDP), spending on health care over the next decade would have to be reduced by 6.2 percent from the amount the Centers for Medicare and Medicaid Services estimates the country would otherwise spend. The authors provide a proposed framework for evaluating some of the options now under consideration including: bundled payment, hospital rate-regulation, HIT, disease management, medical homes, retail clinics, NP-PA scope of practice, and benefit design. The authors contend that although many of the options being considered in the public and private sectors are likely to improve the value of our health care system, only some have the potential to reduce spending. The reform legislation moving through Congress includes both promising and unpromising approaches. The authors conclude by stating that because of the considerable uncertainty surrounding all options, rigorous evaluation methods will be a critical.

Racial and Ethnic Disparities in the Use of High-Volume Hospitals

This study examines the causes of racial and ethnic disparities in health care and treatment outcomes and finds evidence of at least a contributing factor: the hospitals where minority patients seek treatment. The authors found that minorities in the New York City area who require surgery for cancer, cardiovascular procedures, and a number of other medical services are significantly less likely than whites to seek care at hospitals that provide a high volume of those services. It is well established that hospitals that perform a large number of a given surgery or procedure often have better patient outcomes than those that do not. This study raises important questions about the ways in which racial and ethnic groups gain access to medical care. Among the key findings were:

• Black patients were significantly less likely than white patients to use a high-volume hospital for 16 of the 17 services examined between 2001 and 2002. The same was true for Hispanics with regard to 15 services and for Asians with regard to 13 services. 
• The differences were largest for cancer surgeries and cardiovascular procedures, with a more than 20-percentage-point spread, on average, between blacks and whites for 11 services.
• Racial and ethnic differences were found not only for services for which admissions were largely unplanned, but also for those generally planned in advance.

Access to Health Insurance at Small Establishments: What Can We Learn from Analyzing Other Fringe Benefits?

This study found that workers employed by small businesses are less likely than those in large ones to be offered health insurance. Researchers found that 55 percent of full-time workers at very small firms (employing three to 10 workers) were offered health insurance over the study period, compared with 90 percent of employees in firms with 100 or more workers. These employees also were less likely to be offered a retirement plan or paid vacation. In addition, low-wage earners were less likely to be offered health insurance than high-wage earners, regardless of establishment size. Administrative costs are cited as a major reason why so many smaller firms do not offer health benefits to their employees. The authors conclude that insurance exchanges-regulated markets could provide new standardized plan options for employers and employees. The new plans also could provide price and quality information and administer enrollment for employees.

Is More Care Better? The Evidence Suggests No

In this blog post, Jonathan Skinner and Shannon Brownlee examine the relationship between health care spending and utilization in hospitals, on the one hand, and patient outcomes on the other. In an earlier post, John Wennberg and Brownlee rebutted claims that spending and utilization variations among academic medical centers are due to differences in patient income, race, and health status. Many Health Affairs articles and Health Affairs Blog posts have addressed the relationship between spending/utilization and quality. This blog post is a continuation of this debate and discussion.